work-related upper limb wrulds - givengain

in terms of Circular Instruction 180

regarding compensation for work-related

upper limb disorders (WRULDs)

(Compensation for Occupational Injuries

and Diseases Act, 1993

(Act No 130 of 1993), as Amended)

WRULDs

The Compensation

Commissioner’s Guidelines for

Health Practitioners & Employers

to manage

Work-related Upper Limb Disorders

INDEX

SUMMARY: QUICK REFERENCE TO THE EFFECTIVE MANAGEMENT OF WRULDs

SECTION A: INTRODUCTION AND DEFINITION

1 INTRODUCTION 8

1.1 Aim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.3 The impact of WRULDs on the economy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.4 Why it is important to prevent WRULDs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.5 What is covered by Circular Instruction 180 and what not? . . . . . . . . . . . . . . . 9

1.6 Occupational injuries vs. diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1.7 Compensation and prevention (COIDA & OHSA/MHSA) . . . . . . . . . . . . . . . . . 10

2 DEFINITION 11

SECTION B-1: FOR HEALTHCARE WORKERS

3 THE CLASSIFICATION OF WRULDS ACCORDING TO SPECIFIC TYPES OF BODY TISSUE 13

3.1 Tendon-related disorders (tendinopathies) . . . . . . . . . . . . . . . . . . . . . . . . . . 13

3.2 Nerve-related disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

3.3 Bursa-related disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

3.4 Blood vessel disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

3.5 Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

SECTION B-2: FOR HEALTHCARE WORKERS

4 SHOULDER 17

4.1 Relevant anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

4.2 Rotator cuff syndrome (impingement syndrome) . . . . . . . . . . . . . . . . . . . . . . 18

4.3 Other work-related shoulder conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

5 ELBOW 21

5.1 Anatomy of the elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

5.2 Lateral humeral epicondylitis (‘tennis elbow’) . . . . . . . . . . . . . . . . . . . . . . . . 22

5.3 Medial epicondylitis (‘golfer’s elbow’) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

5.4 Other elbow conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

6 WRIST, HAND AND FINGER DISORDERS 23

6.1 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

6.2 De Quervain’s tenosynovitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

6.3 Trigger finger / thumb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

6.4 Carpal tunnel syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

6.5 Tendinopathy of the common flexors / extensors . . . . . . . . . . . . . . . . . . . . . . 27

6.6 Other work-related hand and wrist conditions . . . . . . . . . . . . . . . . . . . . . . . . 27

SECTION C-1: FOR HEALTHCARE WORKERS

7 PRINCIPLES OF DIAGNOSIS 29

7.1 Occupational (and other relevant) history, symptoms, signs and

special investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

7.1.1 Relevant symptoms, clinical signs and progression of the disorder. . . . 29

7.1.2 The history of occupational exposure to the risk factors. . . . . . . . . . . . 31

7.1.3 Relevant facts from the medical, family and social history

as well as the investigation of other potential causes . . . . . . . . . . . . . . 32

7.1.4 Health risk assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

7.1.5 Special investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

7.2 Duration of exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

8 MANAGEMENT OF WRULDs 34

8.1 Clinical significance of the diagnosis of tendinosis . . . . . . . . . . . . . . . . . . . . 34

8.2 Treatment modalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

8.2.1 Employee education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

8.2.2 Anti-inflammatory strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

8.2.3 Therapeutic strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

8.2.4 Reasonable job accommodations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

8.2.5 Surgery as a last resort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

8.3 Algorithms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Algorithm A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Algorithm B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Algorithm C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

9 EVALUATION OF IMPAIRMENT 41

SECTION C-2: FOR THE EMPLOYER

10 REPORTING WRULDs TO THE COMPENSATION COMMISSIONER 43

11 BENEFITS 44

11.1 Temporary total disablement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

11.2 Permanent disablement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

11.3 Medical aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

12 CLAIM PROCESSING 44

SECTION D: FOR THE EMPLOYER

13 REPORTING TO THE INSPECTORATE OF LABOUR 46

STEP 1: Notify the Inspectorate of Labour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

STEP 2: Obtain an ergonomic assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

STEP 3: Compile a plan of action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

STEP 4: Implement the plan of action and review it at appropriate intervals. . . . . . . . 47

Algorithm D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

SECTION E-1: FOR THE EMPLOYER

14 A PRACTICAL APPROACH TO IDENTIFY AND ASSESS RISKS IN THE WORKPLACE WHICH MAY CAUSE WRULDs 50

14.1 Ergonomics and its practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

14.2 Ergonomic analysis – practical steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

14.3 Principles of task/workplace assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

14.3.1 Heed concerns of workers and supervisors . . . . . . . . . . . . . . . . . . . . . 51

14.3.2 Gain better understanding of jobs and tasks . . . . . . . . . . . . . . . . . . . . 51

14.3.3 Identify existing and potential hazards . . . . . . . . . . . . . . . . . . . . . . . . 52

14.3.4 Determine underlying causes of hazards . . . . . . . . . . . . . . . . . . . . . . 52

14.4 Recommend changes and monitor hazard controls (personal protective

equipment, engineering controls, policies, procedures) . . . . . . . . . . . . . . . . . 52

14.5 Workplace observation considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

14.6 Assessing working environment for WRULDs. . . . . . . . . . . . . . . . . . . . . . . . . 52

14.6.1 Ergomax risk calculator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

14.6.2 Using the risk calculator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

14.7 TASK RISKS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

14.7.1 Highly repetitive movements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

14.7.2 Movements requiring force . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

14.7.3 Movements at the extremes of reach . . . . . . . . . . . . . . . . . . . . . . . . . 54

14.7.4 Static muscle loading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

14.7.5 Awkwardly sustained postures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

14.7.6 Contact stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

14.7.7 Vibration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

14.7.8 Load exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

14.7.9 Cold Exposure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

14.8 Additional guidelines to WRULDs assessment. . . . . . . . . . . . . . . . . . . . . . . . 57

14.9 Ergonomic range of motion with safe working zones . . . . . . . . . . . . . . . . . . . 58

14.9.1 Wrist range of motion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

14.9.2 Elbow range of motion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

14.9.3 Shoulder range of motion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

14.10 HUMAN RISKS – Human variables affecting WRULDs risk exposure . . . . . . . . 59

14.10.1 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

14.10.2 Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

14.10.3 Body mass index (BMI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

14.10.4 Exposure history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

14.11 Worked examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

14.11.1 Industrial setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

14.11.2 Office setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

14.12 Ergonomic intervention strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

14.12.1 Deciding how to reduce risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

14.12.2 Ergonomic principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61


15 OCCUPATIONAL HEALTH PROGRAMME 64

15.1 Health risk assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

15.1.1 Medical surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65


16 NEGOTIATE A POLICY ON THE PREVENTION AND MANAGEMENT OF WRULDs 67

16.1 Aim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

16.2 Risk assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

16.3 Information, education and training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

16.4 Work routine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

16.5 Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

16.6 Responding to diagnosed conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

16.7 Redeployment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

16.8 Monitoring and review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

SECTION F: AMINISTRATION AND RESOURCES

17 CIRCULAR INSTRUCTION 180 71

18 W.CL 301: FIRST MEDICAL REPORT 74

19 W.CL 302: PROGRESS/FINAL MEDICAL REPORT 77

20 REPORTING – THE CONTACT DETAILS 80

21 GETTING FURTHER ADVICE 82

22 CHECKLIST: WRULDs IN THE WORKPLACE 85

23 BIBLIOGRAPHY 92

FiguresFigure 1. WRULDs is an umbrella term 11

Figure 2. Tendinosis is the painful degeneration of a tendon, typically caused by overuse (e.g. repetitive

movements, etc.), injury or aging 13

Figure 3. Posterior view of the shoulder complex 19

Figure 4. Anterior view of the shoulder complex 20

Figure 5. Anterior view of the muscles that move the wrist, hand and digits 24

Figure 6. Posterior view of the muscles that move the wrist, hand and digits 25

Figure 7. Trigger finger generally results from swelling within a tendon sheath, restricting tendon

motion. A bump (nodule) may also form 26

Figure 8. The carpal tunnel 26

Figure 9. Early detection and prevention of WRULDs are very important. It is important to be on

the look-out for the ‘fog’ – the level of which indicates perception and awareness of

symptoms. The fog may partly obscure a volcano of WRULDs ready to explode! 64

TablesTable 1. Direct and indirect costs associated with WRULDs 9

Table 2. Bonar’s classification of overuse tendon conditions 14

Table 3. The work-relatedness of musculo-skeletal disorders: Physical work risk factors 17

Table 4. Muscles involved in shoulder (glenohumeral and scapular) movements 18

Table 5. Job activities and tasks typically associated with rotator cuff syndrome 18

Table 6. Muscles that move the humerus, radius and ulna 21

Table 7. Job activities and tasks typically associated with elbow conditions 22

Table 8. Muscles involved in hand, wrist and digit movements 23

Table 9. Job activities and tasks typically associated with De Quervain’s tenosynovitis 24

Table 10. Job activities and tasks typically associated with carpal tunnel syndrome 26

Table 11. Job activities and tasks typically associated with tendinopathy of the common flexors /

extensors 27

Table 12. Job activities and tasks typically associated with hand and wrist conditions 27

Table 13. Symptoms and signs of WRULDs 30

Table 14. Progression of WRULDs 30

Table 15. The risks associated with the development of WRULDs are increased by the following home

or work-based activities 31

Table 16. Example of a template to summarise exposure to risk factors 31

Table 17. Work system factors to be assessed 32

Table 18. Common misconceptions about tendinopathies and its management 34

Table 19. Implications of the diagnosis of tendinosis compared with tendonitis 35

Table 20. The following treatment modalities can be utilised depending on the status of the disorder 36

Table 21. The following documentation should be submitted to the Compensation Commissioner by the

employer individually liable or the mutual association concerned 43

Table 22. Various components of an ergonomics survey 47

Table 22. Some of the main measures that employers can take to prevent WRULDs 62

ACKNOWLEDGEMENTSThe Compensation Office is grateful to the members of its Technical Committee on Occupational Diseases (TCOD)

for their valuable contribution in compiling these comprehensive guidelines and Circular Instruction 180.

These guidelines are the result of consultations with various professional interest groups. We are grateful for the

valuable contributions from:

Afrox Occupational Healthcare (Medical Standards Committee)

Chief Inspector of Mines (Dept of Minerals and Energy)

CSIR Mining Technology

Department of Human Kinetics and Ergonomics, Rhodes University

Department of Labour (Occupational Health & Safety)

Department of Public Health (UCT) – Prof Rodney Ehrlich

Ergomax (Pty) Ltd

Ergonomic Society of South Africa (ESSA)

International Ergonomics Society (Section for Industrial Developing Countries)

Mines Occupational Health Advisory Committee (MOHAC)

National Centre for Occupational Health (NCOH)

Occupational Therapy Association of South Africa (OTASA)

Orthopaedic Association of South Africa

South African Chamber of Commerce (SACOB)

South African Society of Occupational Health Nurses (SASOHN)

South African Society of Occupational Medicine (SASOM)

South African Society of Physiotherapy

South African Society of Surgery of the Hand

Sport Science Institute (UCT) – Prof Tim Noakes

Workability Prevention, Assessment & Work Rehabilitation Services

We acknowledge various institutions around the world who gave permission to quote directly from their publications

and for the use of their illustrations.

Any comments or additional information which can assist the Compensation Commissioner in updating and improv-

ing these guidelines, are being welcomed. Please submit comments in electronic format to the medical officers of

the Compensation Commissioner ([email protected]).

DR MMUSO RAMANTSI

Chief Medical Officer

Compensation Commissioner

9 April 2004

Pretoria

SUMMARYQuick reference to the effective management

of WRULDs

Page | 2 | of 96 pages© 2004 | Compensation Commissioner’s Guidelines for Health Practitioners and Employers to manage WRULDs | Version 1.0

Definition

WRULDs is a collective term for a

group of occupational diseases that

comprise musculo-skeletal disorders

caused by exposure in the workplace

affecting the muscles, tendons,

nerves, blood vessels, joints and

bursae of the hand, wrist, arm and

shoulder. These are syndromes

associated with characteristic

symptoms and physical signs (e.g.

rotator cuff syndrome, epicondylitis

at the elbow, tenosynovitis and nerve

entrapments such as carpal tunnel

syndrome)

1. What are work-related upper limb disorders(WRULDs)?

Classification of WRULDs according to theeffect on specific tissue

Tendon-related disorders Nerve-related disorders Bursa-related disorders

Blood vessel disorders Other

wor

k-related upper limb disordersRSI

Overusesyndrome

& OCDCTD


Shoulder conditions

Fractures around the shoulder

joint

Levator scapulae syndrome

Pectoralis major strains

Rotator cuff syndrome

(Impingement syndrome,

bicipital tendinosis,

infraspinatus tendinosis,

partial tear of the rotator cuff,

subacromial bursitis, subdel-

toid bursitis, subscapularis

tendinosis,

supraspinatus tendinosis)

Rupture of the long head of

the biceps

Elbow conditions

Cubital tunnel syndrome

Lateral humeral epicondylitis

(‘tennis elbow’)

Medial numeral epicondylitis

(‘golfer’s elbow’)

Olecranon bursitis (‘beat

elbow’)

Forearm, wrist, hand and fin-ger conditions

Anterior & posterior

interosseous syndrome

Carpal tunnel syndrome

De Quervain’s tenosynovitis

Guyon (ulnar) tunnel

syndrome

Intersection syndrome

Pronator teres syndrome

Radial tunnel syndrome

Tendinosis / Tenosynovitis of

extensor/flexor tendons

Trigger finger / thumb

White finger (Raynaud’s syn-

drome, vibration syndrome)

2. Some definitive diagnoses of WRULDs*

3. Principles in the diagnosis of WRULDs

(* those marked bold are the more common conditions)

Section 65 (1) (a) of the Compensation for Occupational Injuries and Diseases Act, (No. 130 of 1993) states that

an employee will be entitled to compensation if it is proven to the satisfaction of the Director General that the

employee has contracted a disease mentioned in Schedule 3 and that such a disease has arisen out of and in the

course of his or her employment. Schedule 3 states that musculo-skeletal conditions caused by specific work

activities or a work environment where particular risk factors are present will be regarded as an occupational

disease. Examples of such activities or environment include:

(a) rapid or repetitive motion

(b) forceful exertion

(c) excessive mechanical force concentration

(d) awkward or non-neutral postures

(e) vibration

Compensation for WRULDs caused by exposure to these risk factors are covered in Circular Instruction 180.

Musculo-skeletal diseases which are not of the upper limbs (e.g. neck, lower limbs, etc.) are not covered in the

Compensation Commissioner’s guidelines or in Circular Instruction 180, but can still be reported in terms of

Section 65 (1) (a) of the Compensation for Occupational Injuries and Diseases Act, 1993.

Burning sensation

Fatiguability

Loss of grip strength

Loss of normal sensation

Stiffness and cramps

Muscle weakness

Pain

Paraesthesia (tingling)

Sensation of cold

Swelling


WRULDs tend to be progressive and the development of these disorders can be divided into three broad stages:

Stage 1 Pain, aching and tiredness of the limb are experienced during work, but these symptoms improve

overnight. This stage is most often reversible with rest alone. Sometimes guided exercise and

treatment to address muscular problems are required for a cure

Stage 2 Recurrent pain, aching and tiredness of the limb occur earlier in the day, persist at night and

may disturb sleep. Physical signs of the specific disorder (e.g. swelling) may be visible. These

patients should be referred for physiotherapy and ergonomic assessment to prevent recurrence

Stage 3 Persistent pain, aching, weakness and fatigue of the limb are experienced even if the person had

not been working for some time. Sleep is often disturbed. This can be irreversible if not treated

appropriately

Rapid or repetitive motion

Movements requiring force exertion

Excessive mechanical force concentration

Awkward or non-neutral postures (movementsat extremes of reach, static muscle loading,awkwardly sustained postures, contact stress)

Cold environment or handling chilled or frozenproducts

Vibration

Gender (Females are more at risk)

Age (Older employees are more at risk)

Abnormal body mass index

Prolonged duration of exposure

Poor work organisation (low level of controlover work rate, no breaks, etc.)

Psychosocial stress at work and fatigue

History of occupational exposure to risk factors

Relevant symptoms

Family, medical and social history

Progression of WRULDs

4. The Medical Officers in the Compensation Officewill determine if a diagnosis of a WRULD wasmade according to the acceptable medical standards:

Although symptoms will vary according to the type of disorder, common symptoms include the following:


Perform special investigations

if it is essential for the accurate diagnosis and treatment of the disorder

to investigate and eliminate other causes

Examples

High resolution ultrasound, X-rays, strength testing, range of motion testing, electromyography (EMG)analysis, isokinetic dynamometry

Get prior authorisation for MRI scans from the Compensation Commissioner

Clinical signs

Health risk assessment supporting the clinical findings

Although clinical signs will vary according to the type of disorder, common signs include the following:

Crepitus (crackling sound in subcuta-neous tissue)

Muscle spasm

Muscle weakness

Reduction in range of movement

Swelling

Tender trigger points in muscles

Tenderness

Please note that:

• Symptoms may not always be accompanied by objective signs.

• Any one symptom or sign on its own is not indicative of WRULDs

and some may be common with normal function.

• Very few sufferers experience all the symptoms.

• The symptoms do not appear in any particular order.

Special investigations

COM

PEN

SATI

ONIS

M

Disability

Disorders, injuriesand diseases

requiring medical interventions

Pronounced symptoms make itdifficult to continue usual

activities

Soreness, pain, persistent aches and painsaffect well-being and performance

Occasional movement or posture problems, intermittent discomfort, fatigue, small aches

Fatigue and tiredness, uneasiness and discomfort generally considered ‘normal’ after a full day’s work

VERSUS PREVEN

TIONISM

5. The importance of preventative strategies

Early detection and prevention of WRULDs are very

important – Koemar (1994) described early signs of

WRULDs as the ‘fog’ slumbering in the valley in front

of the mountain. The ‘fog’ may partly obscure a

volcano of WRULDs ready to explode!


Various treatment modalities can be utilised, depending on the status of the disorder. The Compensation

Commissioner will pay for reasonable medical costs once a case has been accepted. A full motivation of the

diagnosis will prevent unnecessary correspondence and delays in adjudication of claim. Health professionals

are encouraged to follow the Compensation Commissioner’s algorithms in managing WRULDs. (See the

Compensation Commissioner’s ‘Guideline for occupational health practitioners & employers to manage work-

related upper limb disorders (WRULDs)’ in terms of Circular Instruction 180)

6. Reporting to the Compensation Commissioner

W. CL. 1 EMPLOYER’S REPORT OF AN OCCUPATIONAL DISEASE OR

W. CL . 305 EMPLOYEE AFFIDAVIT FOR AN OCCUPATIONAL DISEASE (WHEN THE EMPLOYER DOES NOT TIMEOUSLYSUBMIT THE EMPLOYER’S REPORT OF AN OCCUPATIONAL DISEASE (W. CL.1))

W. CL. 14 NOTICE OF AN OCCUPATIONAL DISEASE AND CLAIM FOR COMPENSATION (SIGNED BY THE EMPLOYEE)

W. CL. 110 EXPOSURE HISTORY OR AN APPROPRIATE EMPLOYMENT HISTORY (PLEASE NOTE THAT THE NEW W. CL. 110 FORM SHOULD BE USED)

W. CL. 301 FIRST MEDICAL REPORT IN RESPECT OF A WORK-RELATED UPPER LIMB DISORDER (WRULD)WHEN WRULDS ARE REPORTED, W. CL. 301 MUST BE USED INSTEAD OF THE USUAL W. CL. 22 (FIRSTMEDICAL REPORT IN RESPECT OF AN OCCUPATIONAL DISEASE)

ALL OTHER REPORTS THAT MAY BE RELEVANT TO THE DIAGNOSIS AND TREATMENT OF THE CONDITION (E.G. AN ERGONOMIC ASSESSMENT SUPPORTED BY PHOTOGRAPHS, VIDEO CLIPS, ETC.)

W. CL. 6 RESUMPTION REPORT (EVEN IF THE EMPLOYEE IS AT WORK)

W. CL. 302 PROGRESS/FINAL MEDICAL REPORT IN RESPECT OF A WORK-RELATED UPPER LIMB DISORDER (WRULD)WHEN WRULDS ARE REPORTED, W. CL. 302 MUST BE USED INSTEAD OF THE USUAL W. CL. 26(PROGRESS/FINAL MEDICAL REPORT IN RESPECT OF AN OCCUPATIONAL DISEASE)

As long as the case is open, the employer must submit the following reports on a monthly basis to the Compensation

Commissioner or Mutual Association or employer individually liable, as the case may be, until the employee’s con-

dition has become stabilised, when a Final Medical Report (W.Cl. 302) should be submitted.

The following documentation should be submitted to the Compensation Commissioner, or the employer individual-

ly liable, or the mutual association concerned:

7. Treatment modalities

A. EMPLOYEE EDUCATION

B. ANTI - INFLAMMATORY STRATEGIES

CRYOTHERAPY (ICE)

NON-STEROID ANTI-INFLAMMATORY DRUGS

ELECTROTHERAPEUTIC MODALITIES

(PHYSIOTHERAPY)

INFILTRATION WITH CORTICOSTEROIDS (DUBIOUS

VALUE)

C. THERAPEUTIC STRATEGIES

INITIAL TREATMENT MAY INCLUDE REST

IMMOBILISE – SPLINTAGE (OCCUPATIONAL THERAPY)

MOBILISE (PHYSIOTHERAPY)

MOBILISE – EXERCISE TO APPROPRIATELY

STRENGTHEN MUSCLES (WORKING IN A PROPER

WAY WILL ALSO STIMULATE COLLAGEN

FORMATION)

EDUCATION – GOOD WORK HABITS, PACING, JOINTCONVERSATION TECHNIQUES AND SELF-MANAGEMENT (OCCUPATIONAL THERAPY)

D. REASONABLE JOB ACCOMODATION

TEMPORARY JOB CHANGE

WORK STATION REDESIGN (LAYOUT, HEIGHTS,ETC.)

TOOL AND EQUIPMENT ADAPTATION (CHANGE HANDLE DESIGN, USE OF JIGS, ETC.)

JOB TASK MODIFICATIONS

RETRAINING AND REASSIGNMENT

WORK SCHEDULE MODIFICATIONS

JOB ENLARGEMENT

ROTATION

E. PSYCHOLOGICAL EVALUATION

F. SURGERY (AS LAST RESORT)

SECTION A:Introduction and

Definition

1. Introduction


1.1 Aim

The aim of these guidelines is to give the office of the

Compensation Commissioner and health professionals

dealing with work-related upper limb disorders

(WRULDs) guidance on how to define, diagnose,

manage and report these disorders. It also advises

employers on preventative measures to be taken where

such disorders occur in the workplace and how to

report these to the Department of Labour.

1.2 History

Work-related upper limb disorders (WRULDs) are not a

new phenomenon. They were identified as long ago as

1713 by Ramazzini, an Italian doctor generally

regarded as the father of occupational medicine, who

recognised that serious disease could be caused by

“violent and irregular motions and unnatural postures

of the body”. Ramazzini described symptoms of

WRULD in scribes and clerks, noting that the

“incessant driving of the pen over paper causes

intense fatigue of the hand and the whole arm because

of the continuous strain of the muscles and tendons.”

In the 19th century the condition was recorded

amongst artists, musicians, seamstresses, milkmaids

and smiths. A range of popular terms exists to

describe musculo-skeletal problems associated with

particular occupations: telegraphist’s cramp, hop

picker’s gout, fisherwoman’s finger, upholsterer’s

hand, gamekeeper’s thumb, cotton-twister’s hand,

tennis elbow and, more recently, pizza-cutter’s wrist

and Nintendonitis.1 More recently alternative terms

have been used, i.e. overuse syndrome, repetitive

strain injury (RSI) and cumulative trauma disorder

(CTD). Circular Instruction 180 uses the umbrella

term, work-related upper limb disorders.

Recently musculo-skeletal disorders affecting the upper

limbs have received considerable attention around the

world, following financial claims for damages from

employees considered to have developed WRULDs.

Important differences of opinion still exist, for instance as

to how the disorders should be defined. The term

‘repetitive strain injury’ (RSI) is medically imprecise. A

more descriptive title would be ‘regional pain syndrome’.2

Controversy also arises as to whether certain disorders,

such as carpal tunnel syndrome, are related to workplace

ergonomic factors. Although some of these conditions are

known to be related to non-occupational causes, such as

pregnancy or rheumatoid arthritis, occupational factors

play an important aetiological role in other cases.3

Most of the information regarding WRULDs is

available from developed countries and although many

recommendations will be applicable to developing

countries, there is a need for research on WRULDs in

the South African context. This is particularly

pertinent in industrially developing countries (IDCs)

where there is a high prevalence of manual labour.

This is likely to result in more musculo-skeletal

disorders than is reported in advanced countries.4

1.3 The impact of WRULDs on the economy

No statistics are available for South Africa regarding

the impact of WRULDs on health care and the

economy.5 However, internationally WRULDs are

having an alarming impact, causing significant

occupational health problems, estimated to affect many

millions of employees annually.6

The Unites States of America’s Bureau of Statistics

(1999) reported that among major disabling injuries

and illnesses, the average days away from work were

highest for carpal tunnel syndrome (27 days),

fractures (20 days), and amputations (18 days). Among

the leading events and exposures, repetitive motion

such as grasping tools, lifting bricks and typing,

resulted in the longest absences from work – an

average of 17 days. Conservative estimates calculate

the cost of work-related musculo-skeletal disorders in

the USA at between $13 and $20 billion annually.7

There is substantial evidence within the European

Union that WRULDs are a significant problem with

respect to ill health and associated costs within the

workplace. It is likely that the size of the problem will

increase as more employees are becoming exposed to

1 London Hazard Centre (1997). Ch 4, p1.

2 NIOSH (1997). p 23.

3 HSE (1996). Introduction, p 1.

4 Scott P et al. (2002)

5 SAMOSA (2002)

6 Personal communication – Prof PA Scott, Department of Human Kinetics and

Ergonomics, Rhodes University, South Africa

7 NIOSH (1997)


workplace risk factors for these disorders within the

European Union.8

Where data do exist (e.g. in the Nordic countries and

the Netherlands) the cost has been estimated at

between 0.5% and 2% of Gross National Product.9

In Britain, the Health and Safety Executive (HSE)

estimated that WRULDs incurred approximate costs of

£1.25 billion per year10.

Although there are limited records on the incidence of

WRULDs in South Africa, it is very likely to be

substantially higher than that reported for the USA

and Europe. This is due to the excessive physical

demands placed on employees in industrially

developing countries.

The direct costs for compensation of musculo-skeletal

disorders are appreciated far more than the indirect

costs associated with disruptions in productivity and

quality, worker replacement costs, training and other

work absence costs. It is believed that the direct costs

due to compensated work-related musculo-skeletal

disorders are a relatively low proportion of the total

costs.11

1.4 Why it is important to prevent WRULDs

WRULDs may have severe consequences if prompt

action is not taken, such as:

Decreased productivity due to pain and increased

fatigue.

Inability to work. Well motivated and productive

people have had to give up work because of pain

and disablement from WRULDs. Others have been

so badly affected that simple household tasks

become difficult.

Lost production when employees take time off

sick.

Compensation claims from those who have to stop

working because of WRULDs.

The Occupational Health and Safety Act and the

Mine Health and Safety Act require employers to

assess health and safety risks, and to put meas-

ures in place to ensure the health and safety of

employees.

Failure to comply could lead to legal action against

the employer by the Department of Labour, who

administers the Occupational Health and Safety

Act, or the Department of Minerals and Energy,

who administers the Mine Health and Safety Act.

1.5 What is covered by Circular Instruction180 and what not?

Section 65 (1) (a) of the Compensation for

Table 1. Direct and indirect costs associated with WRULDs

DIRECTCOSTS ±20%

MEDICAL EXPENSES

EMPLOYEES COMPENSATION PREMIUMS

LOST WORKDAYS

PAID LEAVE

INDIRECTCOSTS ±80%

LOSS OF INJURED WORKER’S PRODUCTION

TIME LOST BY UNINJURED EMPLOYEES

TEMPORARY RE-PLACEMENT

TRAINING AND RE-TRAINING

REPORTING AND CLAIMS

MANAGEMENT TIME

WORKER / MANAGEMENT DISCUSSIONS

LITIGATION PROCESSES

8 European Agency for Safety and Health at Work (1999). Summary p. 7

9 European Agency for Safety and Health at Work (1999). Ch 2.3, p. 23

10 HSE (1996). Ch 2.3, p. 23

11 Hagberg M et al. (1995).

Occupational Injuries and Diseases Act, (No. 130 of

1993) states that an employee will be entitled to

compensation if it is proven to the satisfaction of the

Director General that the employee has contracted a

disease mentioned Schedule 3 and that such a

disease has arisen out of and in the course of his or

her employment. Schedule 312 states that musculo-

skeletal diseases caused by specific work activities or

work environment where particular risk factors are

present will be regarded as an occupational disease.

Examples of such activities or environment include:

(a) rapid or repetitive motion

(b) forceful exertion

(c) excessive mechanical force concentration

(d) awkward or non-neutral postures

(e) vibration

Compensation for WRULDs caused by exposure to these

risk factors are covered in Circular Instruction 180.

Musculo-skeletal diseases which are not of the upper

limbs (e.g. neck, lower limbs, etc.) are not covered in

these guidelines or in Circular Instruction 180, but

can still be reported in terms of Section 65 (1) (a) of

the Compensation for Occupational Injuries and

Diseases Act, 1993.

It is necessary to emphasise the importance of referring

employees to adequately trained and experienced

health professionals when a WRULD is suspected.

These include occupational medicine practitioners,

physiotherapists, occupational therapists, ergonomists,

and orthopaedic specialists, amongst others.

1.6 Occupational injuries vs. diseases

A case of WRULD will be regarded as an occupational

disease and not as an ‘injury’ – and should therefore

be reported as such.

However, if a case of WRULD develops as a result of

an occupational injury (e.g. a fracture into the wrist

joint with the consequent development of carpal

tunnel syndrome), the WRULD should be considered

part of the injury and the Compensation Commissioner

should be notified in the subsequent progress reports

of the occupational injury.

1.7 Compensation and prevention (COIDA & OHSA/MHSA)

WRULDs must be reported to the Compensation

Commissioner so that payment of medical costs, sick

leave and compensation can be considered in terms of

the COID Act (Table 20, p. 43).

WRULDs should also be reported to the Provincial

Executive Manager of Labour (in terms of the Occu-

pational Health and Safety Act) or to the Regional

Principal Inspector of Mines (in terms of the Mine

Health and Safety Act) so that they can ascertain

whether the health hazards causing this disease were

reduced through ergonomic improvement.

Useful forms and templates are included as addenda

to these guidelines. These templates may be used or

adapted to suit individual circumstances. It is not

compulsory to use these forms or templates, but it is

highly recommended.


12 Amendment of Schedule 3 as published in Government Gazette [Number 26302 – 30 April 2004]

2. Definition

Work-related upper limb disorders are occupationally-

induced conditions that develop over time to affect

the musculo-skeletal and peripheral nervous system of

the upper limbs.

Previously a number of other terms have been used

which probably describe the same entities, but in the

strictest sense do not overlap completely,13 such as

repetitive strain injury (RSI), cumulative trauma

disorder (CTD), occupational overuse syndrome (OOS),

occupational cervico-brachial disorder (OCD), etc. For

the purpose of this instruction the umbrella term,

work-related upper limb disorders (WRULDs), will be

used. This can be represented simply by Figure 1

(HSE, 1996) shown below.

The symptoms of pain and loss of motion can be the

result of fatigued muscles, overloaded muscles,

muscle imbalances, degeneration of tendons and their

attachments, inflamed tendon sheaths or compressed

nerves.

There is controversy surrounding the work-relatedness

of many musculo-skeletal disorders, and it is likely

that many of those reported in the workplace have a

multifactorial origin with psychosocial and contribut-

ing individual factors. There is, however, strong

evidence of a causal relationship between at least

some of these conditions, and repetitive, forceful work

involving the body parts affected and/or the sustained

postures adopted during work.

Circular Instruction 180 states that WRULDs are caused,

aggravated or precipitated by one or more of the

following risk factors, singly or in combination:

Highly repetitive movements

Movements requiring force

Movements at the extremes of reach

Static muscle loading

Awkwardly sustained postures

Contact stress (e.g. uncomfortable gripping and

twisting, sharp edges to hand tools, desk edges, etc.)

Vibration

In terms of this instruction, upper limb musculo-

skeletal disorders will be presumed to be work-related

(Table 3, p. 17) if the nature of the work performed

includes exposure to the relevant risk factors.

Work-related musculo-skeletal disorders of body parts

other than the upper limbs are not covered in Circular

Instruction 180 or these guidelines, but it will be con-

sidered in terms of Section 65 (1) (b) of the Compens-

ation for Occupational Injuries and Diseases Act.


wor

k-related upper limb disordersRSI

Overusesyndrome

& OCDCTD

Figure 1. WRULDs is an umbrella term

WRULDs is a collective term for a group of occupational

diseases that comprise musculo-skeletal disorders caused by

exposure in the workplace affecting the muscles, tendons,

nerves, blood vessels, joints and bursae of the hand, wrist, arm

and shoulder. These are syndromes associated with

characteristic symptoms and physical signs (e.g. rotator cuff

syndrome, epicondylitis at the elbow, tenosynovitis and nerve

entrapments such as carpal tunnel syndrome).

13 HSE (1996). Section 1, p 1.

SECTION B-1:For healthcare workers

Classification

3. The classification of WRULDs according to specific types of body tissue

WRULDs can be classified according to the

specific types of body tissue that are involved.14

Various degrees of, and variations of the following

conditions can be the result of overuse:

Tendon-related disorders

Nerve-related disorders

Bursa-related disorders

Blood vessel disorders

Other


14 European Agency for Safety and Health at Work (1999). Ch 2.1, p 16.

15 Personal communication with Prof Tim Noakes (UCT Sports Science Institute)

16 Used with the permission of Mayo Foundation for Medical Education and

research (© 1998–2002)

17 Khan, K (2000).

18 Perugia L et al (1986 )

19 Evans, G (1997)

One factor that may interfere with optimal treatment

is that common tendinopathies may be mislabelled as

tendonitis. Advances in the understanding of tendon

pathology indicate that conditions that have been tra-

ditionally labelled as lateral epicondylitis, rotator cuff

tendonitis, etc., are in fact tendinosis. An increasing

body of evidence supports the notion that these over-

use tendon conditions do not involve inflammation

(“-itis”), but collagen degeneration (“-osis”). If this is

correct, then the traditional approach to treating

tendinopathies as an inflammatory tendonitis is likely

to be flawed.17

Tendinosis is intratendinous collagen degeneration

commonly due to aging, microtrauma (e.g. chronic

overuse with repetitive movements), or vascular com-

promise.

The term tendinosis was first used by German

researchers in the 1940s. Perugia18 noted the

‘remarkable discrepancy between the terminologies

generally adopted for these conditions (which are

obviously inflammatory since the ending itis is used)

and their histopathologic substratum, which is largely

degenerative.’

Thus, occupational health practitioners must shift

their perspective and acknowledge that tendinosis is

the pathology being treated in most cases and that

treatment needs to combat collagen breakdown rather

than inflammation. Tendinosis may require a reason-

able period of relative rest and attention to strength-

ening with the aim of first breaking the tendinosis

cycle. Once this is done, the patient uses modalities

that optimise collagen production and maturation so

that the tendon achieves the necessary tensile

strength for normal function.

Examples: Epicondylitis (tennis and golfer’s elbow),

rotator cuff impingement syndrome of the shoulder, etc.

Tenosynovitis: Rapid, repetitive movements of the

upper extremities, particularly the hands and fingers,

can cause inflammation of the synovial lining of the

tendon sheath.19 The consequent swelling causes pain

and impedes movement of the tendon in the sheath.

3.1 Tendon-related disorders(tendinopathies)

Khan (2000) and Noakes (2002)15 stated that numerous

investigators worldwide have shown that the pathology

underlying overuse tendinopathies is primarily tendi-

nosis (i.e. collagen degeneration).

Figure 2. Tendinosis is the painful degeneration of a tendon, typicallycaused by overuse (e.g. repetitivemovements, etc.), injury or aging16

Bursa

Muscle

Tendon

© Mayo Foundation for Medical Education and Research. All rights reserved.

It is called tenosynovitis. Repeated exposure ultimately

causes the growth of scar tissue and results in pain,

reduced mobility and weakness. 20

Examples: Trigger finger, De Quervain’s tenosynovitis,

etc.

Tendonitis is inflammation of tendons and of tendon-

muscle attachments.21 It is a rather rare condition,

but may occur occasionally in the Achilles tendon in

conjunction with a primary tendinosis.22 Many

clinicians and medical publications still mistakenly

use the term tendonitis (inflammation), when they

actually mean tendinosis (degeneration).

3.2 Nerve-related disorders

Repeated or prolonged pressure or irritation can cause

damage to the nerve that supplies the muscle or

passes through it. The nerve irritation causes paraes-

thesia (numbness, tingling) and changes in sensation

in the areas supplied by the nerve.23

Examples: Carpal tunnel syndrome (by far the most

common), cubital tunnel syndrome, Guyon tunnel

syndrome, pronator teres syndrome, radial tunnel

syndrome, anterior interosseous nerve syndrome,

posterior interosseous nerve entrapment etc.

3.3 Bursa-related disorders

Bursas are ‘cushions’ which protect muscles, tendons

and skin from friction against bones (e.g. at the elbow

and shoulder, during movements of the joints).24 (See

Figure 2). Overexertion can lead to inflammation in

these bursas and causes a dull aching pain, called

bursitis.25 It can also cause an effusion within the sac

of the bursa.

Examples: Olecranon bursitis (beat elbow), subacro-

mial burisits, subdeltoid bursitis, etc.

3.4 Blood vessel disorders

Work-related blood vessel disorders are usually due to

vibration or hammering. Exposure to vibration at the

hand interface and its effects on biological tissues are

well established and it is generally recognised that

excessive exposure may result in disturbances to


Table 2. Bonar’s classification of overuse tendon conditions

PATHOLOGIC MACROSCOPIC HISTOLOGICAL F INDINGDIAGNOSIS PATHOLOGY

TENDINOSIS INTRATENDINOUS DEGENERATION COLLAGEN DISORIENTATION, DISORGANISATION, AND FIBRE

COMMONLY DUE TO AGING, MICRO- SEPARATION BY INCREASED MUCOID GROUND SUBSTANCE,

TRAUMA, OR VASCULAR COMPROMISE INCREASED PROMINENCE OF CELLS AND VASCULAR SPACES

WITH OR WITHOUT NEOVASCULARISATION, AND FOCAL

NECROSIS OR CALCIFICATION

PARTIAL RUPTURE SYMPTOMATIC DEGENERATION OF THE DEGENERATIVE CHANGES AS NOTED ABOVE WITH SUPER-

OR TENDINIT IS TENDON WITH VASCULAR DISRUPTION, IMPOSED EVIDENCE OF TEAR, INCLUDING FIBROBLASTIC AND

INFLAMMATORY REPAIR RESPONSE MYOFIBROBLASTIC PROLIFERATION, HAEMORRHAGE, AND

ORGANISING GRANULATION TISSUE

PARATENDONITIS INFLAMMATION OF THE OUTER LAYER MUCOID DEGENERATION IS SEEN IN THE AREOLAR TISSUE: A

( INCLUDING OF THE TENDON (PARATENDON) ALONE SCATTERED MILD MONONUCLEAR INFILTRATE WITH OR

TENOSYNOVIT IS) WHETHER OR NOT THE PARATENDON WITHOUT FOCAL FIBRIN DEPOSITION AND FIBRINOUS EXUDATE

IS LINED BY SYNOVIAL

PARATENDONITIS PARATENDONITIS ASSOCIATED WITH DEGENERATIVE CHANGES AS NOTED IN TENDINOSIS WITH

( INCLUDING INTRATENDINOUS DEGENERATION MUCOID DEGENERATION WITH OR WITHOUT FIBROSIS AND

TENOSYNOVIT IS) SCATTERED INFLAMMATORY CELLS IN THE PARATENON

WITH TENDINOSIS ALVEOLAR TISSUE

20 Bridger, RS (1995). p. 135

21 HSE (1996). Ch 3, p. 5

22 Khan, K (2000)

23 Bridger, RS (1995). p. 136

24 Bridger, RS (1995). p. 136

25 House of Commons (1998). p. 12

Source: Khan (2000)

finger blood circulation and also neurological and

locomotor functions of the hand and arm.26&27

Examples: Raynaud’s phenomenon, hand-arm vibra-

tion syndrome, hypothenar hammer syndrome, etc.

3.5 Other

The effect of work on muscles and joints are problem-

atic (e.g. static loading can cause muscle imbal-

ances28 and trigger points29). (Keep in mind that

static loading of proximally situated muscles may be

more affected than tendons situated more distally).

Muscles and joints form, per definition, part of upper

limb disorders, such as tension neck syndrome,

muscle sprain and strain (biceps strain, torn

muscles), myalgia and myositis, and osteoarthritis.

But the effect of work on muscles and joints are very

controversial and fall outside the scope of these

guidelines. The same applies to musculo-skeletal

‘injuries’, because in these guidelines we are only

dealing with ‘occupational diseases/disorders’ of the

upper limb.


26 European Agency for Safety and Health at Work (1999). Ch 5.6, p. 70

27 Mennen (1999)

28 Pheasant et al. (1991)

29 MacKinnon et al. (1997)

SECTION B-2:For healthcare workers

Shoulder, Elbow, Wrist,Hand and Fingers

CARPAL TUNNEL SYNDROME

TENDINOSIS

HAND-ARM VIBRATION SYNDROME

SHOULDER

4. Shoulder

4.1 Relevant anatomy

Healthy shoulder function is essential for many work-ing tasks. Manual materials handling (MMH) tasks,particularly those involving lifting and lowering ofloads, may place considerable cumulative stress onthe shoulder joint. Sound knowledge of the functionalanatomy and dynamic forces acting around the shoul-der joint is important to understand the pathologicalprocesses that commonly affect this area. The shoul-der (glenohumeral) joint is a ball and socket joint and

stability of this joint is provided by static and dynam-

ic constraints. Static constraints include the gleno-

humeral ligaments, glenoid labrum and capsule. The

dynamic constraints are predominantly the rotator

cuff musculature (refer Figure 3. p.17 and Figure 4,

p. 18). An understanding of the musculature involved

in certain shoulder movements will help to determine

the structures likely to be more strained. Presented in

Table 4 are movements of the shoulder complex and

the muscles involved in these movements.


BODY PART STRONG EVIDENCE EVIDENCE INSUFFICIENT EVIDENCE OF RISK FACTOR EVIDENCE NO EFFECT

Table 3. The work-relatedness of musculo-skeletal disorders: Physical work risk factors

NECK AND NECK/SHOULDER

REPETITION QFORCE QPOSTURE QVIBRATION Q

REPETITION QFORCE QPOSTURE QVIBRATION Q

REPETITION QFORCE QPOSTURE QCOMBINATION QHAND/WRIST

ELBOW

REPETITION QFORCE QPOSTURE QVIBRATION QCOMBINATION Q

REPETITION QFORCE QPOSTURE QCOMBINATION Q

VIBRATION QSource: NIOSH (1997)


30 Bridger RS. (1995). Ch 5, p. 140 31 Uhthoff HK et al. (1991)

4.2 Rotator cuff syndrome (impingement syndrome)

The shoulder is particularly prone to damage where

persons are executing repetitive overhead move-

ments.30 The same applies to static loading and/or sus-

tained postures. They are prone to develop bursal side

tears secondary to impingement in the rotator cuff

region.31 (See Figure 2, p.14)

Table 4. Muscles involved in shoulder (glenohumeral and scapular) movements

MOVEMENT PRIME MOVERS SECONDARY MOVERS

FLEXION ANTERIOR DELTOID PECTORALIS MAJOR (CLAVICULAR HEAD)

CORACOBRACHIALIS

EXTENSION LATISSIMUS DORSI TERES MINOR

TERES MAJOR TRICEPS

POSTERIOR DELTOID

ABDUCTION MID DELTOID ANTERIOR/POSTERIOR DELTOID

SUPRASPINATUS SERRATUS ANTERIOR

ADDUCTION PECTORALIS MAJOR TERES MAJOR

LATISSIMUS DORSI

EXTERNAL ROTATION INFRASPINATUS POSTERIOR DELTOID

TERES MINOR

INTERNAL ROTATION SUBSCAPULARIS ANTERIOR DELTOID

PECTORALIS MAJOR

LATISSIMUS DORSI

TERES MAJOR

GLE

NO

HU

ME

RA

L

RETRACTION RHOMBOID MAJOR/MINOR

TRAPEZIUS

PROTRACTION SERRATUS ANTERIOR PECTORALIS MINOR

UPWARD ROTATION TRAPEZIUS

SERRATUS ANTERIOR

DOWNWARD ROTATION RHOMBOIDS LATISSIMUS DORSI

PECTORALIS MINOR

ELEVATION TRAPEZIUS

LEVATOR SCAPULAE

RHOMBOIDS

DEPRESSION LATISSIMUS DORSI

PECTORALIS MINOR

SC

AP

ULA

R

Source: Scott, P. et al. (2002)

Table 5. Job activities and tasks typically associated with rotator cuff syndrome

B E LT C O N V E Y O R A S S E M B LY

L I F T I N G

PA C K I N G

C A R R Y I N G L O A D O N S H O U L D E R S

O V E R H E A D A S S E M B LY

P U N C H P R E S S O P E R AT I O N

C O N S T R U C T I O N W O R K

O V E R H E A D PA I N T I N G

R E A C H I N G

E L E C T R I C A L W O R K

O V E R H E A D W E L D I N G

W O R K W I T H T H E A R M S AW AY F R O M T H E B O D Y

Source: Guild R, et al. (2001)

Figure 3. Posterior view of the shoulder complex35


Shoulder pain exacerbated by abduction against

resistance is a sign of rotator cuff lesions. Although an

active range of movement of the joint is limited by

pain, passive range of motion remains approximately

normal.32 Acute rotator cuff tendinosis is diagnosed if

the symptoms are of 12 weeks duration or less.

Chronic rotator cuff rupture presents a marked

difficulty initiating abduction with weakness and

limitation of movement.33 Pain is usually experienced

towards the end of the active range of movement.34 An

understanding of the ‘painful arc’ is a useful diagnos-

tic tool. Pain is usually reproduced in the range of 70o

to 120o abduction.

Rotator cuff syndrome (impingement syndrome)includes the following conditions:

Bicipital tendinosis

Infraspinatus tendinosis

Partial tear of the rotator cuff

Subacromial bursitis

Subdeltoid bursitis

Subscapularis tendinosis

Supraspinatus tendinosis

Tendonisis of the shoulder

4.3 Other work-related shoulder conditions

Rupture of the long head of the biceps

Pectoralis major strains

Levator scapulae syndrome

Fractures around the shoulder joint

32 Cyriax J (1988)

33 Vecchio P et al. (1995)

34 Cyriax J (1988)

35 Taken from Tortora (2002)

First thoracic vertebra

ClavicleAcromion of scapula

Spine of scapula

DELTOID

Long head of triceps brachii

SUPRASPINATUS (cut)

Scapula

TERES MAJORCORACOBRACHIALIS

Humerus

LATISSIMUS DORSI

Spinous process offirst lumbar vertebra

Iliac crestThoracolumbar fascia

Levator scapulae (cut)

RHOMBOIDEUS MINOR (cut)

DELTOID (cut)

INFRA-SPINATUS

TERES MINORRHOMBOIDEUS MAJOR (cut)

TERES MAJOR

Humerus

Figure 4. Anterior view of the shoulder complex36



DELTOID (cut)

SUPRASPINATUS

SUBSCAPULARIS

PECTORALIS MAJOR (CUT)

TERES MAJOR

Biceps brachii (cut)CORACOBRACHIALIS

LATISSIMUS DORSI

Brachialis

Biceps brachii (cut)

Radius

Ulna

10th rib

Internal intercostals

External intercostals

Serratus anterior

Sternum

Pectoralis minor

PECTORALIS MAJOR (cutcut)

2ND ribSerratus anterior

Coracoid process of scapulaSubclaviusClavicle

5. Elbow

5.1 Anatomy of the elbow

Use of the upper limb during many work activities

demands a well-functioning elbow. Refer to Figure 3,

Figure 4, Figure 5 and Figure 6 while reading through

the table below which lists the muscles involved in

the movement of the humerus, radius and ulna.

Epicondylitis is a common and well-defined clinical

entity affecting the elbow. It is a tendinosis charac-

terised by pain at the epicondyle, due to intratendi-

nous degeneration of the tendon-bone attachment. It

is more frequent laterally (‘tennis elbow’) than

medially (‘golfer’s elbow’). Epicondylitis is due to

unusual force, repetition, forceful gripping or

repeated supination and pronation.37

Entrapment neuropathies of the forearm should

always be suspected with ‘resistant’ tennis elbow

(e.g. radial tunnel syndrome can mimic lateral

epicondylitis).38


Table 6. Muscles that move the humerus, radius and ulna

MOVEMENT PRIME MOVERS SECONDARY MOVERSFLEXION PECTORALIS MAJOR (CLAVICULAR HEAD)

ANTERIOR DELTOID

CORACOBRACHIALIS

EXTENSION PECTORALIS MAJOR (STERNOCOSTAL HEAD)

LATISSIMUS DORSI

POSTERIOR DELTOID

TERES MAJOR

TERES MINOR

ABDUCTION LATERAL DELTOID SUPRASPINATUS

ADDUCTION PECTORALIS MAJOR INFRASPINATUS

LATISSIMUS DORSI TERES MAJOR

TERES MINOR

CORACOBRACHIALIS

MEDIAL ROTATION PECTORALIS MAJOR TERES MAJOR

LATISSIMUS DORSI

ANTERIOR DELTOID

SUBSCAPULARIS

LATERAL ROTATION POSTERIOR DELTOID

INFRASPINATUS

TERES MINOR

HU

ME

RU

S

F LEXION BICEPS BRACHII

BRACHIALIS

BRACHIORADIALIS

EXTENSION TRICEPS BRACHII

ANCONEUS

PRONATION PRONATOR TERES

PRONATOR QUADRATUS

SUPINATION SUPINATORRA

DIU

S A

ND

ULN

A

Source: Scott et al. (2002)

37 HSE (1996). Ch 4, p. 1 38 HSE (1996)

5.2 Lateral humeral epicondylitis (‘tenniselbow’)

Lateral elbow pain is very common in manual employ-

ees with the most common cause being overuse. This

condition has traditionally been referred to as ‘lateral

epicondylitis’. The primary pathological process

involved in this condition is degeneration of the

extensor carpi radialis brevis (refer Table 6 and Table

8). Although a common disorder, there are many other

injuries which can affect the elbow and which impede

movements of the humerus, radius and ulna.39

Wrist dorsiflexion, such as in the power grasp, and

exposure of the arms to high forces and repetitive

tasks can lead to degeneration at the attachment of

the extensor muscles of the wrist to the lateral

humeral epicondyle.

This condition also often starts with an acute direct

injury to the site of the muscle origin which progresses

to an epicondylitis.

5.3 Medial epicondylitis (‘golfer’s elbow’)

Overuse of the finger flexors and the wrist

flexors/pronators, as in repetitive work with the elbow

flexed, leads to pain in the common proximal flexor

origin on the medial aspect of the elbow.40

5.4 Other elbow conditions

Olecranon bursitis (beat elbow)41

Cubital tunnel syndrome


39 Scott, P. et al (2002)

40 Williams N (1993) 41 HSE (1996). Ch 4, p. 11

Table 7. Job activities and tasks typically associated with elbow conditions

EPICONDYLIT IS

DRILLERS

CARPENTERS

POLISHERS

TURNING SCREWS

SMALL PARTS ASSEMBLY

HAMMERING

REPETITIVE WRIST EXTENSION

REPETITIVE WRIST GRASP

COMPUTER USERS

CUBITAL TUNNELSYNDROME

RESTING FOREARM NEAR ELBOW ON A HARD SURFACE

RESTING FOREARM NEAR ELBOW ON SHARP EDGE

RESTING FOREARM NEAR ELBOW WHILE REACHING OVER OBSTRUCTION

REPETITIVE OR STATIC ELBOW FLEXION

Source: Bridger (1995); Guild et al. (2001)

6. Wrist, hand and finger disorders

6.1 Anatomy

Although the wrist and hand are frequently trauma-

tised during work, there is a tendency to overlook the

severity of the injuries to these areas, with the result

that a number of important conditions are not

diagnosed. Overuse conditions to the wrist are

common, while direct trauma to the hand and digits is

another concern. Presented in Figure 5 (p. 24) and

Figure 6 (p. 25) are the musculature of the wrist,

hand and digits. The anterior compartment muscles

function as flexors, and the posterior compartment

muscles function as extensors. Outlined below in

Table 8, are the muscles involved in various wrist,

hand and digit movements.

6.2 De Quervain’s tenosynovitis

De Quervain’s tenosynovitis is sometimes called

stenosing tenosynovitis of the abductor pollices

longus and extensor pollices brevis tendons. The

patient presents with pain over the styloid process of

the radius. A common and well-recognised variant of

De Quervain’s tenosynovitis is characterised by a

localised swelling at the base of the thumb and thick-

ening of the fibrous sheath or reticulum. Sometimes a

palpable nodule, of which the precise cause is

unknown, can be felt in the course of the abductor

pollicis longus and extensor pollicis brevis tendons.42

This condition can result from overuse of the thumb,

such as in the repetitive grasping of a straight handled


42 HSE (1996). Ch 4, p. 6

Table 8 Muscles involved in hand, wrist and digit movements

MOVEMENT PRIME MOVERS SECONDARY MOVERS

FLEXION FLEXOR CARPI RADIALIS

FLEXOR CARPI ULNARIS PALMARIS LONGUS

FLEXOR DIGITORUM PROFUNDUS

EXTENSION EXTENSOR CARPI RADIALIS

EXTENSOR CARPI RADIALIS BREVIS

EXTENSOR DIGITORUM

EXTENSOR CARPI ULNARIS

EXTENSOR POLLICIS BREVIS

EXTENSOR INDICIS

ABDUCTION ABDUCTOR POLLICIS LONGUS FLEXOR CARPI RADIALIS

EXTENSOR CARPI RADIALIS

EXTENSOR POLLICIS LONGUS

ADDUCTION FLEXOR CARPI ULNARIS

EXTENSOR CARPI ULNARIS

TH

E W

RIS

T A

ND

HA

ND

F LEXION FLEXOR DIGITORUM SUPERFICIALIS (MIDDLE PHALANX)

FLEXOR POLLICIS LONGUS (THUMB)


EXTENSION EXTENSOR DIGITORUM

EXTENSOR DIGITI MINIMI (L ITTLE FINGER)

EXTENSOR POLLICIS BREVIS (THUMB) ABDUCTOR POLLICIS BREVIS (THUMB)

EXTENSOR POLLICIS LONGUS (THUMB)

EXTENSOR INDICIS ( INDEX FINGER)

ABDUCTION ABDUCTOR POLLICIS LONGUS (THUMB)

DIG

ITS

Source: Scott et al. (2002)

tool (e.g. screwdriver, endo files of dentist). The

tendons of the muscles of the forearm are stretched

and rub against the radial styloid, causing inflamma-

tion of the tendon sheath and leading to pain and

localised swelling (tenosynovitis of the first dorsal

compartment of the wrist) over the lateral aspect of

the distal radius.43 Incidentally, this condition is also

common in post-partum women.

Diagnostic criteria suggest pain and tenderness

localised to the radial aspect of the wrist plus a

positive Finkelsteins’s test (ask patient to make a fist

over his thumb, and ulnarly deviating wrist – sharp

pain at this site is produced by active extension and

abduction of the thumb against resistance).44


43 Bridger RS (1995). p. 145

44 HSE (1996). Ch 4, p. 6 45 Taken from Tortora (2002)

Figure 5. Anterior view of the muscles that move the wrist, hand and digits45

Table 9. Job activities and tasks typically associated with De Quervain’s tenosynovitis

B U F F I N G

G R I N D I N G

P O L I S H I N G

S A N D I N G

E N D O F I L I N G ( D E N T I S T )

P U S H I N G

P R E S S I N G

S AW I N G

U S E O F P L I E R S

U S E O F S M A L L T O O L S

‘ T U R N I N G ’ C O N T R O L S A S O N M O T O R C Y C L E

I N S E R T I N G S C R E W S I N H O L E S

F O R C E F U L H A N D W R I N G I N G

Source: Guild et al. (2001)

Biceps brachii

Brachialis

Brachial arteryMedian nerve

PRONATOR TERESBRACHIORADIALIS

SUPINATORPALMARIS LONGUSFLEXOR CARPI RADIALISFLEXOR CARPI ULNARIS

PRONATOR TERES (cut)

FLEXOR DIGITORUM SUPERFICIALIS

FLEXOR POLLICIS LONGUS

ABDUCTOR POLLICIS LONGUS

PRONATOR QUADRATUS

flexor retinaculum

MetacarpalsTendon of flexor digitorum superficialis

Tendon of flexor digitorum profundus

(a) Anterior superficial view (b) Anterior deep view

Palmaris longusPronator teresFlexor carpi radialisFlexor digitorum superficialisFlexor carpi ulnaris


Medial epicondyle of humerusTendon of biceps brachii

De Quervain’s tenosynovitis must be differentiated

from degenerative arthritis of the trapeziometacarpal

joint. The Grind Test is used to differentiate, which

will usually be negative in De Quervain’s, but positive

in degenerative arthritis. (The Grind Test is performed

by holding the thumb’s proximal phalanx and the

metacarpal phalangeal joint in the examiner’s hands

and forcefully pushing against trapeziometacarpal

joint, while also rotating it slightly, to cause a grind-

ing motion).47 It must also be differentiated from

Intersection48 and Wartenberg’s syndromes.49

6.3 Trigger finger / thumb

Trigger finger or thumb is tenosynovitis and/or tendi-

nosis of the finger’s or the thumb’s flexor tendons,

causing an inability to move the fingers or thumb

smoothly and the locking of the affected digit, with or

without pain. This stenosing tenosynovitis can be

caused by using hand tools that have sharp edges

pressing into the tissue or whose handles are too far

apart for user.50 Repetitive movements with repeated

or prolonged gripping or pinching can also cause oper-

ating trigger finger. 51

Concomitant diseases and/or reasons for trigger finger

(e.g. rheumatoid arthritis, diabetes, etc.) should be

investigated as part of the differential diagnosis.52

6.4 Carpal tunnel syndrome

A totally different range of conditions that are loosely

associated with the overuse syndromes, are the condi-

tions which result from direct or indirect pressure on

nerves, of which carpal tunnel syndrome is the most

frequently encountered.



47 Wheeless CR (1996)

48 Intersection syndrome is a painful condition that affects the thumb side of

the forearm where two muscles (abductor pollicis longus and extensor

pollicis brevis) cross over – or intersect – two underlying wrist tendons

(extensor carpi radialis longus and brevis)

49 Wartenberg's syndrome: Radial sensory nerve entrapment causing significant

pain in the lower third of the forearm.

50 Guild R, et al. (2001)

51 House of Commons (1998). p. 13

52 Channas M, et.al. (1995)

Figure 6. Posterior view of the muscles that move the wrist, hand and digits46

Triceps brachii

ANCONEUSEXTENSOR CARPI ULNARIS

EXTENSOR CARPI RADIALIS BREVIS

EXTENSOR DIGITI MINIMI

FLEXOR CARPI ULNARISFLEXOR DIGITORUM

PROFUNDUS

ABDUCTOR POLLICISLONGUS

Tendon of extensor carpi ulnaris

Extensor retinaculumCarpals

Tendon of extensorindicis

Dorsal interosseiTendons of extensordigitorum

Tendon of extensordigiti minimi

EXTENSOR DIGITORUM

HumerusBRACHIORADIALIS

EXTENSOR CARPIRADIALIS LONGUS

Medial epicondyle of humerusLateral epicondyle of humerus

Olecranon of ulna

SUPINATOR

Tendon of pronator terres

EXTENSOR POLLICIS LONGUSEXTENSOR POLLICIS

LONGUS EXTENSOR INDICIS(a) Posterior superficial view

(b) Posterior deep view

Figure 7. Trigger finger generallyresults from swelling within a tendonsheath, restricting tendon motion. Abump (nodule) may also form53

Carpal tunnel syndrome is a common ailment affect-

ing the wrist and hand. The majority of cases of carpal

tunnel syndrome are not caused by work. Carpal tun-

nel syndrome can have many non-occupational causes

and is more prevalent in women than in men. It is

common during pregnancy.54 It was also found to

occur twice as often in both hands as in either the

dominant or non-dominant hand alone.

There is evidence that there are specific occupations

where the wrists are positioned in abnormal positions

for prolonged periods, and also in highly repetitive

wrist movements where tenosynovitis of the flexor ten-

dons can exert pressure on the median nerve in the

carpal tunnel. These symptoms start with a gradual

onset of tingling and numbness in the fingers and can

progress to pain, clumsiness and muscle atrophy in

the hand.55

The clinical diagnosis is made with a positive Tinel’s

sign (pain, numbness, or tingling in the median nerve

distribution resulting from tapping over the proximal

wrist crease) and a positive Phalen’s sign or reverse

Phalen’s sign (pain, numbness, or tingling in the

median nerve distribution resulting from complete

palmar flexion and dorsiflexion respectively, of the

wrist for 60 seconds).56

It should not be forgotten that a direct injury to the

wrist area can also cause the same condition, acutely

(haematoma causing pressure on the nerve) or more

subacutely, like a fracture, which may cause swelling

or cause a deformity.

Figure 8. The carpal tunnel57


53 Used with the permission of Nucleus Medical Art, Inc., www.nucleusinc.com

54 Souhami RL et al. (1990), p.1033

55 Bridger RS (1995). p. 138

56 NIOSH (1989)

57 Used with the kind permission of Medem Inc. and the American Medical

Society

Table 10. Job activities and tasks typically associated with carpal tunnel syndrome

B U F F I N G

G R I N D I N G

A S S E M B LY W O R K

T Y P I N G

P R E H E N S I L E TA S K E S P E C I A L LY I N E X T R E M E S O F F L E X I O N , E X T E N S I O N A N D U L N A R D E V I AT I O N

PA C K I N G

S C R U B B I N G

H A M M E R I N G

R E P E T I T I V E O R F O R C E F U L G R I P

C O M P U T E R W O R K

P O L I S H I N G

S A N D I N G


Copyright © 2004Nucleus Medical Art, Inc.All rights reserved.www.nucleusinc.com

Swollen tendon

Bent finger

Carpastunnel

Ligament

Median nerve

Tendonsheaths

Tendons

6.5 Tendinopathy of the common flexors / extensors of the forearm


Table 11. Job activities and tasks typically associated with tendinopathy of the common flexors / extensors of the forearm

Table 12. Job activities and tasks typically associated with hand and wrist conditions

T E N D I N O PAT H Y ( E . G . T E N D I N O S I S ,T E N O S Y N O V I T I S )

PUNCH PRESS OPERATION POLISHING

ASSEMBLY WORK SANDING

WIRING PUNCH PRESS OPERATION

PACKAGING SAWING

USE OF PLIERS CUTTING

BUFFING USE OF PLIERS

GRINDING FORCEFUL HAND WRINGING

‘TURNING’ CONTROLS SUCH INSERTING SCREWS IN HOLES

AS ON MOTORCYCLE

G U Y O N T U N N E L S Y N D R O M E

( B I K E R ’ S F I N G E R )

R E P E AT E D / P R O L O N G E D P R O L O N G E D F L E X I O N O F A N D

P R E S S U R E O N T H E O U T S I D E O F E X T E N S I O N O F T H E W R I S T

T H E PA L M B R I C K L AY I N G

C A R P E N T R Y S O L D E R I N G

U S E O F P L I E R S H A M M E R I N G

P R O N AT O R T E R E S S Y N D R O M E

S O L D E R I N G B U F F I N G

S A N D I N G G R I N D I N G

P O L I S H I N G

W H I T E F I N G E R( R AY N A U D ’ S S Y N -

D R O M E , V I B R AT I O N S Y N D R O M E )



W O R K I N G W I T H C H A I N S AW, J A C K H A M M E R S , U S I N G V I B R AT I N G T O O L

T H AT I S T O O S M A L L F O R T H E H A N D , O F T E N I N A C O L D

E N V I R O N M E N T

6.6 Other work-related hand and wrist conditions

Radial tunnel syndrome

Guyon (ulnar) tunnel syndrome

Pronator teres syndrome

Anterior and posterior interosseous syndrome

Intersection syndrome

SECTION C-1:For healthcare workers

Diagnosis, management &evaluation of impairment

7. Principles of Diagnosis

WRULDs caused by rapid or repetitive motion, force-

ful exertion, excessive mechanical force concentra-

tion, awkward or non-neutral postures and vibration

have been included in Schedule 3 of the

Compensation for Occupational Injuries and Diseases

Act, 1993.

In Circular Instruction 180 these risk factors are men-

tioned in more detail, namely highly repetitive move-

ments, movements requiring force, movements at the

extremes of reach, static muscle loading, awkwardly

sustained postures, contact stress (e.g. uncomfortable

gripping and twisting, sharp edges to hand tools, desk

edges, etc.) and vibration. (See 14.7, p. 53 on how to

assess for these risk factors.)

The implication is that employees only have to prove

that they are exposed to these risk factors at work and

it will be presumed that they developed the specific

WRULD as a result of their work, provided investiga-

tions for potential other causes have been reasonably

excluded. This will have to correlate with their job and

the specific condition – employees cannot claim they

have tendinosis of the elbow if they do repetitive

movements with their legs!!

According to Circular Instruction 180 the following

criteria should be applied to confirm the diagnosis:

a. A diagnosis of a WRULD by the medical practition-

er.

b. Medical history and clinical signs indicating –

– site and distribution

– quality (type, character)

– severity (intensity, frequency, duration) and

– progression of the symptoms according to the

type of disorder

c. Functional ability report by an occupational thera-

pist and / or physiotherapist, where necessary.

d. Occupational exposure to known risk factors and a

chronological relationship between the WRULD

and the work environment.

e. Confirmatory tests/investigations (e.g. X-rays,

strength testing, range of motion testing, nerve

conduction tests), where appropriate.

The medical officers in the Compensation Office will

determine whether the diagnosis of WRULD was made

according to acceptable criteria.

7.1 Occupational (and other relevant) history, symptoms, signs and specialinvestigations

7.1.1 Relevant symptoms, clinical signs and progres-sion of the disorder

The presence of specific symptoms and objective

signs (accurately described and evaluated) associated

with this alleged, specific disorder is necessary to

make a definitive diagnosis. Pain, swelling and func-

tion should be evaluated.

The progression of the injury over a period of time is

important to help determine the prognosis.

When the worker is examined, there must be an exam-

ination routine. It is important that both the uninjured

and injured sides are examined. Try and reproduce the

symptoms, assess for referred pain, examine the spine

and perform functional testing. It is important that

the area be palpated, that ligaments are tested and

that nerve function be assessed.

It is not the purpose of these guidelines to go into

depth on how to examine the upper limb. However,

occupational health practitioners are advised to famil-

iarise themselves thoroughly with the Southampton

examination schedule for the diagnosis of musculo-

skeletal disorders of the upper limb.58


58 Palmer K et al. (2000)

Table 13 – Symptoms and signs of WRULDs


SYMPTOMS

STAGE 1

Although symptoms will vary according to the type of disorder, common symptoms and signs include the following:

B U R N I N G S E N S AT I O N

FAT I G U A B I L I T Y

L O S S O F G R I P S T R E N G T H

L O S S O F N O R M A L S E N S AT I O N

S T I F F N E S S A N D C R A M P S

M U S C L E W E A K N E S S

PA I N

PA R A E S T H E S I A ( T I N G L I N G )

S E N S AT I O N O F C O L D

S W E L L I N G

PA I N , A C H I N G A N D T I R E D N E S S O F T H E L I M B I S E X P E R I E N C E D W H E N W O R K -

I N G , B U T T H E S E S Y M P T O M S I M P R O V E O V E R N I G H T. T H I S S TA G E I S M O S T

O F T E N R E V E R S I B L E W I T H R E S T A L O N E . S O M E T I M E S G U I D E D E X E R C I S E A N D

T R E AT M E N T T O A D D R E S S M U S C U L A R P R O B L E M S A R E R E Q U I R E D F O R A C U R E .

STAGE 2

R E C U R R E N T PA I N , A C H I N G A N D T I R E D N E S S O F T H E L I M B O C C U R E A R L I E R I N

T H E D AY, P E R S I S T AT N I G H T A N D M AY D I S T U R B S L E E P. P H Y S I C A L S I G N S O F

T H E S P E C I F I C D I S O R D E R ( E . G . S W E L L I N G ) M AY B E V I S I B L E . T H E S E PAT I E N T S

S H O U L D B E R E F E R R E D F O R P H Y S I O T H E R A P Y A N D W O R K A S S E S S M E N T T O

P R E V E N T R E C U R R E N C E .

STAGE 3

P E R S I S T E N T PA I N , A C H I N G , W E A K N E S S A N D FAT I G U E O F T H E L I M B A R E

E X P E R I E N C E D E V E N I F T H E P E R S O N H A D N O T B E E N W O R K I N G F O R S O M E

T I M E . S L E E P I S O F T E N D I S T U R B E D . T H I S C A N B E I R R E V E R S I B L E I F N O T

T R E AT E D A P P R O P R I AT E LY.

C R E P I T U S ( C R A C K L I N G S O U N D I N S U B C U TA N E O U S T I S S U E )

M U S C L E S PA S M

M U S C L E W E A K N E S S

R E D U C T I O N O F R A N G E M O V E M E N T

S W E L L I N G

T E N D E R T R I G G E R P O I N T S I N M U S C L E S

T E N D E R N E S S

S IGNS

Please note that:

Symptoms may not always be accompanied by objective signs.

Any one symptom or sign on its own is not indicative of WRULDs and some may be common with normal function.

Very few sufferers experience all the symptoms.

The symptoms do not appear in any particular order.

Table 14. Progression of WRULDs – WRULDs tend to be progressive and the development of the disorder can be divided into three broad stages

Source: London Hazard Centre (1997)

7.1.2 The history of occupational exposure to the riskfactors

A summary is needed of the current working environ-

ment with respect to the flow of work and the actions

required by the employee to complete the work.

Summarise the exposure to the risk factors (See Table

16 and 17). The summary table should be completed

by the medical practitioner when completing the

Medical Reports for WRULDs (W.Cl. 301 & W.Cl. 302

forms).

Refer to the posture/s adopted by the employee to

conduct the work, the force and motion required, and

the exposure to vibration. Consider which of these fac-

tors contributed to the alleged upper limb disorder in

relation to the frequency of the movements, duration,

strength and range of movement.


R A P I D O R R E P E T I T I V E M O T I O N

M O V E M E N T S R E Q U I R I N G F O R C E E X E R T I O N

E X C E S S I V E M E C H A N I C A L F O R C E C O N C E N T R AT I O N

AW K W A R D O R N O N - N E U T R A L P O S T U R E S

( M O V E M E N T S AT E X T R E M E S O F R E A C H , S TAT I C

M U S C L E L O A D I N G , AW K W A R D LY S U S TA I N E D

P O S T U R E S , C O N TA C T S T R E S S )

C O L D E N V I R O N M E N T O R H A N D L I N G C H I L L E D O R

F R O Z E N P R O D U C T S

V I B R AT I O N

G E N D E R ( F E M A L E S A R E M O R E AT R I S K )

A G E ( O L D E R E M P L O Y E E S A R E M O R E AT R I S K )

A B N O R M A L B O D Y M A S S I N D E X

P R O L O N G E D D U R AT I O N O F E X P O S U R E

P O O R W O R K O R G A N I S AT I O N ( L O W L E V E L O F C O N -

T R O L O V E R W O R K R AT E , N O B R E A K S , E T C . )

P S Y C H O S O C I A L S T R E S S AT W O R K A N D FAT I G U E

Table 15. The risks associated with the development of WRULDs are increased bythe following home or work-based activities

Table 16. Example of a template to summarise the exposure to risk factors

RISK FACTOR PERCENTAGE OF BRIEFLY DESCRIBE THE JOB TASK WHERE THIS RISK WORKING DAY FACTOR OCCURS AND QUANTIFY IN TERMS OF

REPETITIONS/DURATION/ STRENGTH REQUIRED/RANGE OF MOVEMENT, ETC.

R E P E T I T I V E M O V E M E N T S

M O V E M E N T S R E Q U I R I N GF O R C E

M O V E M E N T S AT T H EE X T R E M E S O F R E A C H

S TAT I C M U S C L E L O A D I N G

AW K W A R D LY S U S TA I N E DP O S T U R E S

C O N TA C T S T R E S S

V I B R AT I O N

L O W T E M P E R AT U R E S( C O L D )


Table 17. Work system factors to be assessed

PHYSICAL PROPERTYPOSTURE

STRENGTH & RANGE REPETITION/ DURATIONOF MOVEMENT FREQUENCY(AMPLITUDE / MAGNITUDE)

F O R C E F O R C E G E N E R AT E D F R E Q U E N C Y O F T I M E T H AT F O R C E I SO R A P P L I E D A P P L I C AT I O N A P P L I E D

P O S T U R E J O I N T A N G L E F R E Q U E N C Y T I M E H E L D

M O T I O N V E L O C I T Y, A C C E L E R AT I O N F R E Q U E N C Y O F M O T I O N T I M E O F M O T I O N E X P O S U R E

V I B R AT I O N A C C E L E R AT I O N F R E Q U E N C Y W I T H W H I C H T I M E O F V I B R AT I O NV I B R AT I O N O C C U R S E X P O S U R E

Source: European Agency for Safety and Health at Work (1999)

Note:

Acute injuries can develop into chronic injuries if there is inadequate rehabilitation before returning to work.

When this progression of an acute injury is reported to the Compensation Commissioner, one must continue to

handle it as an occupational injury and not as an occupational disease (WRULD), because it was reported as an

injury in the first place (thus use W. Cl. 5 to complete progress medical reports).

State the period(s) the employee worked in previous

environments with exposures related to his/her

disease (start with the most recent employer mention-

ing the period of exposure, the occupation, the type of

exposure, the year first exposed, the duration / years

of exposure (which may not be the same as the years

in an occupation), the frequency of exposure (e.g.

once per week for an hour or 8 hours every day).

If necessary, attach photos, diagrams and/or extra

reports to explain the employee’s work actions.

7.1.3 Relevant facts from the medical, family andsocial history as well as the investigation ofother potential causes

It is important that all non-vocational activities (e.g.

sport) are investigated to determine how these

conditions contribute to the development of any of the

symptoms. An upper limb disorder may be seen as a

consequence of activities performed at work, but it

could also be caused by the worker’s domestic or

recreational activities and not work.

Previous injuries, leisure activities, lifestyle issues

and other non work-related activities which could lead

to the development of this disorder, should thus be

determined.

Proof should also be given that other potential causes

have been investigated, where appropriate (e.g.

hypothyroidism, diabetes, pregnancy, rheumatologic

disorders, etc., in the case of carpal tunnel syndrome;

and X-rays to exclude neck pathology where

indicated).

7.1.4 Health risk assessment

The medicine practitioner who makes the definitive

diagnosis should familiarise himself with the alleged

work environment, work process and work actions.

7.1.5 Special investigations

Special investigations should be carried out if

considered essential for the accurate diagnosis

and treatment of the injury (e.g. high resolution

ultrasound X-rays, strength testing, range of

motion testing, electromyography (EMG) analysis,

isokinetic dynamometry, etc.). The Compensation

Commissioner will not pay for magnetic resonance

imaging (MRI) scan if prior authorisation had not

been obtained from the medical officers in the

Compensation Commissioner’s office.

7.2 Duration of exposure

WRULDs take a period of time to develop and gener-

ally a job which involves exposure to the mentioned

risk factors, should be performed for more than 6

months before the condition develops. However, each

case should be evaluated on its own merit.


8. Management OF WRULDs

Definitions:

Occupational health practitioner (OHP): A

registered nursing sister with an extra

qualification in occupational health, also

often referred to as the occupational

health nurse (OHN).

Occupational medicine practitioner (OMP):

A medical doctor with an extra qualifica-

tion in occupational health.


59 Personal communication with Prof Tim Noakes (UCT Sport Science Institute)

60 Khan K (2000) 61 Khan K (2000)

8.1 Clinical significance of the diagnosis oftendinosis

Evidence supports the notion that overuse tendon con-

ditions do not primarily involve inflammation, but

degeneration.59 If this is correct, then the traditional

approach to treating tendinopathies as an inflammato-

ry ‘tendonitis’ is likely flawed. Current scientific data

(Table 18) will help physicians avoid common miscon-

ceptions about tendinopathies and their management.60

If we accept that a worker with overuse tendinopathy

has a disorder that is due to collagen degeneration,

then the diagnosis has various implications for the

management of these disorders (Table 19).61

Table 18. Common misconceptions about tendinopathies and its management

MISCONCEPTION

TENDINOPATHIES ARE SELF-LIMITING CONDITIONS THAT TAKE

ONLY A FEW WEEKS TO RESOLVE

EVIDENCE-BASED FINDING

TENDINOPATHIES OFTEN PROVE RECALCITRANT TO

TREATMENT AND MAY TAKE MONTHS TO RESOLVE

IMAGING APPEARANCE CAN PREDICT PROGNOSIS

IMAGING DOES NOT PREDICT PROGNOSIS; IT ADDS

TO THE LIKELIHOOD OF A DIAGNOSIS OF TENDINOPATHY BUT

DOES NOT PROVE IT

CYST-LIKE ULTRASONOGRAPHIC ABNORMALITIES IN

TENDONS ARE INDICATIONS FOR SURGERY

SURGERY IS GENERALLY NOT INDICATED.

AS LAST RESORT, SURGERY SHOULD BE BASED ON

CLINICAL GROUNDS; CYST-LIKE ULTRASONOGRAPHIC

FINDINGS CAN BE FOUND IN ASYMPTOMATIC EMPLOYEES

SURGERY PROVIDES RAPID RELIEF OF SYMPTOMS

IN ALMOST ALL SUBJECTS

AFTER SURGERY (WHERE IT WAS CLINICALLY INDICATED AS

LAST RESORT), RETURN TO REPETITIVE WORK TAKES A

MINIMUM OF 4-6 MONTHS; NOT ALL PATIENTS DO WELL

Source: Khan K (2000)

8.2 Treatment modalities

Khan (1998) presented a new paradigm in the manage-

ment of tendinopathies in sports medicine. This

approach has a record of clinical effectiveness and

recent research adds further scientific support.62

This approach in sports medicine was therefore

adapted for these guidelines to fit occupational health

and the management of WRULDs, since the under-

lying mechanism of tissue damage is presumably the

same, namely repetitive movements, overuse, excessive

force and overloading.

Prof Tim Noakes (2002) of the Sport Science Institute

(University of Cape Town) agrees that this assumption

is justified and that it is supported by sound scientific

research.63

Tendinopathies have caused long-lasting frustration

for employees, employers and occupational health

practitioners, because they attributed the pathology to

tendonitis, rather than tendinosis. Occupational

health practitioners should acknowledge that the

cause is most often due to tendinosis, rather than

tendonitis, and treat the problem using a fundamen-

tally different paradigm. Advice and suggestions for

employees along these lines of clinical thought can

help them recover more quickly and prevent surgery.

8.2.1 Employee education

The occupational health practitioner should take the

time to explain and illustrate the pathology of

tendinosis, especially since textbooks and websites

have yet to embrace this pathology and its clinical

implications. Employees who have symptoms of short

duration, but are still able to engage in work, are the

ones who need the most education. They are likely to

continue to do repetitive work without undergoing

appropriate treatment, and thus worsen the

tendinosis.64


62 Khan (1998)

63 Personal communication with Prof Tim Noakes (December 2002) 64 Khan (2000)

Table 19. Implications of the diagnosis of tendinosis compared with tendonitis

TRAIT OVERUSE TENDINOSIS OVERUSE TENDONITIS

PREVALENCE COMMON RARE

TIME FOR RECOVERY, EARLY PRESENTATION 6-10 WEEKS SEVERAL DAYS TO 2 WEEKS

TIME FOR FULL RECOVERY, CHRONIC 3-6 MONTHS 4-6 WEEKSPRESENTATION

LIKELIHOOD OF FULL RECOVERY FROM CHRONIC SYMPTOMS TO RESUMEREPETITIVE WORK ~80% 99%

FOCUS OF CONSERVATIVE THERAPY ENCOURAGEMENT OF COLLAGEN- ANTI-INFLAMMATORY MODALITIESSYNTHESIS MATURATION AND AND DRUGSSTRENGTH

ROLE OF SURGERY AS LAST RESORT EXCISE ABNORMAL TISSUE NOT KNOWN

PROGNOSIS FOR RECOVERY AFTER SURGERY 70%-85% 95%

TIME TO RECOVER FROM SURGERY 4-6 MONTHS 3-4 WEEKS

Source: Khan K (2000)

8.2.2 Anti-inflammatory strategies

Common anti-inflammatory strategies include:

Cryotherapy (ice)

Electrotherapeutic modalities (physiotherapy)

Non-steroidal anti-inflammatory drugs (NSAIDs)

Corticosteroid injections

Employees with tendinosis may benefit from cryo-

therapy, because ice has a vasoconstrictive role, and

abnormal neovascularisation is a feature of the pathol-

ogy. Because a strong clinical impression exists that

ice is helpful in tendinopathies, this modality should

not be discarded.65

Limited evidence exists to support the use of NSAIDs

and corticosteroids in treating tendinosis.66, 67 NSAIDs

on the other hand are effective in the treatment of

tenosynovitis, which is an inflammatory condition.

Corticosteroid injection has lost favour in managing

tendinosis, because tendinosis is not an inflammatory

condition.68, 69 It may still have a role to play in the

treatment of tenosynovitis.

8.2.3 Therapeutic strategies

Therapeutic strategies are used to improve the

individual’s functional capacity and some of the

modalities which are used, include:

Initial treatment may include rest

Immobilise – splinting (occupational therapy)

Physiotherapy modalities, e.g. ultrasound for

tenosynovitis

Mobilise – stretches to improve flexibility (physio-

therapy)

Mobilise – exercise to appropriately strengthen

muscles (physiotherapy)

Education – good work habits, pacing, joint con-

servation techniques and self-management (occu-

pational therapy)

8.2.4 Reasonable job accommodations

Temporary job change

Work station redesign (layout, heights, etc)


65 Khan (2000)

66 Almekinders et al. (1998)

67 Khan(2000)

68 Shrier et al. (1996)

69 Khan(2000)

Table 20. The following treatment modalities can be utilised depending on the statusof the disorder

A. EMPLOYEE EDUCATION

B. INFLAMMATORY STRATEGIES

CRYOTHERAPY (ICE)

NON-STEROID ANTI-INFLAMMATORY DRUGS

ELECTROTHERAPEUTIC MODALITIES

(PHYSIOTHERAPY)

INFILTRATION WITH CORTICOSTEROIDS

C. THERAPEUTIC STRATEGIES

INITIAL TREATMENT MAY INCLUDE REST

IMMOBILISE – SPLINTAGE

(OCCUPATIONAL THERAPY)

MOBILISE (PHYSIOTHERAPY)

MOBILISE – EXERCISE TO APPROPRIATELY

STRENGTHEN MUSCLES

EDUCATION – GOOD WORK HABITS, PACING, JOINT

CONVERSATION TECHNIQUES AND

SELF-MANAGEMENT (OCCUPATIONAL THERAPY)

D. REASONABLE JOB ACCOMODATION

TEMPORARY JOB CHANGE

WORK STATION REDESIGN (LAYOUT, HEIGHTS,

ETC.)

TOOL AND EQUIPMENT ADAPTATION (CHANGE HAN-

DLE DESIGN, USE OF JIGS, ETC.)

JOB TASK MODIFICATIONS

RETRAINING AND REASSIGNMENT

WORK SCHEDULE MODIFICATIONS

JOB ENLARGEMENT

ROTATION

E. PSYCHOLOGICAL EVALUATION

F. SURGERY (AS LAST RESORT)

Tool and equipment adaptation (change handle

design, use of jigs etc)

Job task modification

Retraining and reassignment

Work schedule modifications (half day initially,

build up to full day)

Job enlargement (inclusion of additional duties to

reduce repetitiveness of performing a single task only)

Rotation

8.2.5 Surgery as a last resort

Surgery has been considered the treatment of last

resort for tendinopathies, and this certainly applies, if not

more so, for a confirmed case of tendinosis. Surgery

can be used to excise tissue affected by tendinosis,

but surgery has not been proven to stimulate collagen

synthesis or maturation. Reviews suggest that surgery

in tendinosis has a 75% to 85% success rate.70, 71

Therefore, an important implication of tendinopathy’s

underlying pathology being tendinosis is that conser-

vative management must progress slowly. Because

surgical treatment of tendinosis is not without failure,

and recovery takes a minimum of 4 to 6 months, this

treatment should be reserved for failure of a high-

quality programme of conservative management.72 If

surgery is required, rehabilitation should start pre-

surgery in order to improve post-surgery recovery. This

includes physiotherapy, occupational therapy and

exercise therapy.

8.3 Algorithms

Algorithms A, B and C73 (p. 38 – 40) offer OHNs and

OMPs guidelines on how to manage a possible case of

WRULD.

The rationale behind these algorithms in managing

WRULDs is:

That of a typical occupational health clinic in an

industrial setting

With an occupational nursing practitioner as the

primary contact

And the visiting occupational medicine practition-

er or general practitioner as secondary contact

Where this is not the case, these algorithms will still

give a health practitioner a good idea of the process to

be followed in managing and reporting a WRULD to

the Compensation Commissioner. See ‘Reporting’

(p. 43) for forms which should be used.

Page | 37 | of pages© 2004 | Compensation Commissioner’s Guidelines for Health Practitioners and Employers to manage WRULDs | Version 1.0

70 Coleman BD; Khan KM; Maffulli, et al. (2000)

71 Coleman BD; Khan KM; Kiss ZS, et al. (2000)

72 Khan(2000)

73 Adapted for South African circumstances from a NIOSH Health Hazard

Evaluation Report (HETA 89-307-2009) by Afrox Occupational Healthcare

ALGORITHM A

PRIMARY CONTACT: GUIDELINES FOR THE OCCUPATIONAL NURSING PRACTITIONER

WHEN A WRULD IS SUSPECTED. THE OCCUPATIONAL HEALTH NURSING PRACTITIONER

HAS AN IMPORTANT ROLE IN EVALUATING AND SCREENING ORDINARY MUSCLE ACHES

AND PAINS FOR POTENTIAL WRULDs.

ALGORITHM B

SECONDARY CONTACT: GUIDELINES FOR THE OCCUPATIONAL HEALTH MEDICINE

PRACTITIONER BEFORE A WRULD IS REPORTED TO THE COMPENSATION

COMMISSIONER

THE DOCTOR USUALLY EVALUATES THOSE EMPLOYEES NOT RESPONDING TO THE

OHN’S CONSERVATIVE MANAGEMENT. THE DOCTOR NOW HAS THE TASK TO EVALUATE

THE WORK-RELATEDNESS OF THE SYMPTOMS, AND THEN HAS TO DECIDE IF AN OCCU-

PATIONAL INJURY OR AN OCCUPATIONAL DISEASE (WRULDs) SHOULD BE REPORTED

TO THE COMPENSATION COMMISSIONER.

ALGORITHM CGUIDELINES TO THE OCCUPATIONAL HEALTH MEDICINE PRACTITIONER WHEN REPORT-

ING A CASE OF WRULD TO THE COMPENSATION COMMISSIONER

ALGORITHM D GUIDELINES TO THE EMPLOYER IN REPORTING WRULDs TO THE DEPT OF LABOUR


A Guidelines for the occupational nursing practitioner (OHN) when a work-related upper limbmusculo-skeletal disorder (WRULD) is suspected

A WORKER COMPLAINS ABOUT UPPER L IMB MUSCULO-SKELETAL SYMPTOMS

1. RX 1

2. TEMPORARY JOB CHANGE

3. SPLINTAGE AS APPROPRIATE

1. RX 2

2. REFER TO OCCUPATIONALMEDICINE PRACTITIONER (OMP)

PAIN

CONTINUES TO WORK AND RE-EVALUATE AFTER 3-5 DAYS

SYMPTOMSIMPROVE

SYMPTOMSIMPROVE

CONTINUESRX 1

CONTINUE WITH RX 2

RE-EVALUATE AFTER 3-5 DAYS



SYMPTOMSRESOLVE

SYMPTOMSRESOLVE

SYMPTOMS DONOT IMPROVE

SYMPTOMS DONOT IMPROVE

SYMPTOMSCONTINUE

SYMPTOMSCONTINUE

CONTINUES WITHREGULAR JOB

RETURNS TOREGULAR JOB

PAIN WITH CREPITUS OR NUMBNESS

1. NON-STEROIDAL ANTI-INFLAMMATORY DRUGS, ETC. (A)

2. ICE (B)

3. GENTLE EXERCISE (C)

4. OHN VISITS WORK STATION

RX 1 RX 2

ABOUT THESE ALGORITHMS

The rationale behind these algorithms is a typical occupational health clinic in an industrial setting with an occupational health nurse, as wellas an occupational medicine practitioner (doctor) or general practitioner visiting a few hours per week. Where this is not the case, these algorithms will still give a health practitioner a good idea of the process to be followed in reporting a WRULD to the Compensation Commissioner,as well as the investigation of other potential causes.

• Algorithm [A] is meant for the occupational health nursing practitioner to screen workers, to initiate treatment and to make appropriate recommendations after an initial visit to the work station (i.e. simple adjustments, recommend full ergonomic assessment by competent person, etc.).

• Algorithm [B] is meant for the visiting in-house medical practitioner and gives guidance on how to work up a case before reporting the WRULDto the Compensation Commissioner. No ‘external’ medical costs should be encountered during this phase (i.e. the on-site occupational healthclinic should be able to handle it satisfactorally and referrals to the public health sector can help with initial tests, etc.).

• Algorithm [C] refers to the reporting of a worker with WRULD by an occupational medicine practitioner. ‘External’ medical costs may beencountered (i.e. outside the scope of a typical occupational health industrial clinic) in the treatment and rehabilitation of a worker. If thecase is accepted, the Compensation Commissioner may pay for reasonable medical costs, as well as the sick leave.

• Algorithm [D] gives guidance to the employer on how to respond if a case of WRULD has been reported.

a = Ibuprofen 400 mg 3 times per day per mouth or Aspirin 600mg 2 times per day per mouth and Ointment to rub painfularea

b = Ice to area for 20 minutes 4 times per day c = Under nursing supervision for first day

PAIN WITH REDNESS OR SWELLING

1

P R I M A R Y C O N TA C T

OHN TAKES HISTORY, EXAMINES WORKER AND VISITS THE WORKSTATION AND MAKES INITIAL RECOMMENDATIONS

THE OCCUPATIONAL HEALTH NURSING PRACTITIONER HAS AN IMPORTANT ROLE IN EVALUATING AND SCREENING ORDINARY MUSCLE ACHESAND PAINS FOR POTENTIAL WRULDs.

1. CONTINUE WITH RX 22. REFER TO OMP

SECONDARY CONTACT

DOCTOR TAKES MEDICAL, OCCUPATIONAL AND SOCIAL HISTORY AND DOES A PHYSICAL EXAMINATION, MAKES A PSYCHOLOGICAL IMPRESSION,AS WELL AS A WORKING DIAGNOSIS AND VISITS THE WORKSTATION.

THE DOCTOR USUALLY EVALUATES THOSE WORKERS NOT RESPONDING TO THE OHN’S CONSERVATIVE MANAGEMENT. THE DOCTOR NOW HAS THE TASK TO EVALUATE THE WORK-RELATEDNESS OF THE SYMPTOMS, AND THEN NEEDS TO DECIDE IF AN OCCUPATIONALINJURY OR AN OCCUPATIONAL DISEASE (WRULD) SHOULD BE REPORTED TO THE COMPENSATION COMMISSIONER.


NO SYMPTOMS

B Guidelines for the occupational medicine practitioner (OMP) before a work-related upperlimb disorder (WRULD) is reported to theCompensation Commissioner

REFERRAL FROM ONP TO OMP / GENERAL PRACTIT IONER

S Y M P T O M S R E M A I N O R W O R S E N

1. OMP VISITS WORKSTATION & GIVESADVICE

2. NSAID INJECTION (D)

3. PHYSIO / OCCUPATIONAL THERAPY (E)

4. REST FOR 2-3 WORKING DAYS

5. CONTINUE RX 1

6. SPLINTAGE AS APPROPRIATE

IMPROVED SYMPTOMS – RETURNS TOREGULAR OR TEMPORARY JOB

BACK TO REGULAR JOB

CONTINUES WITH TEMPORARY JOB

NO SYMPTOMS

RE-EVALUATE IN 3-7 DAYS

MANAGE FURTHER AND REFER TO TER-T IARY LEVEL IF NECESSARY. THE

COMPENSATION COMMISSIONER WILL NOT

ACCEPT RESPONSIBIL ITY FOR ANYCLAIMS OR MEDICAL EXPENSES.


STILL MILD SYMPTOMS

NOT CONVINCING EVIDENCE OF WRULD SOUND EVIDENCE OF WRULD

DO NOT REPORT TO COMPENSATION COMMISSIONER

REPORT TO COMPENSATIONCOMMISSIONER (G)

IN GAUTENG – PLEASE ALSO REPORT TO SAMOSA (H)

WORSENINGSYMPTOMS

MUCH IMPROVED OR NO SYMPTOMS

BACK TO TEMPORARY JOB APPROPRIATE MEDICAL

WORK UP (F )


RX 3

d = Diclofenac 50 – 75 mg IMI e = Consider physiotherapy and/or occupational therapy where these services are available (e.g. at the day hospital - the

Compensation Commissioner will not pick up these costs at this stage).f = Where appropriate, do special investigations to exclude other non work-related causes (e.g.ESR, thyroid functions,

rheumatoid screening in the case of carpal tunnel syndrome; X-rays of the neck may be necessary to exclude cervical spondylosis; X-rays of a specific joint may also be indicated, etc). The Compensation Commissioner is notresponsible for these costs!

g = Please inform the worker beforehand that medical costs will only be paid if the case is accepted. Huge amounts ofcompensation will most probably not be forthcoming.

h = SA Occupational Musculo-skeletal Disorder Surveillance Action Group (SAMOSA),National Centre for OccupationalHealth, Johannesburg. (Tel/Fax 011 725 5978; [email protected]).

NO IMPROVEMENT IN SYMPTOMS

2

1


SYMPTOMS REMAIN OR WORSEN

C Guidelines for the occupational medicine practitioner (OMP) when a WRULD is reported tothe Compensation Commissioner


EVALUATE PROGRESS FOR 2-3 MONTHS

PREVENTATIVE MEASURES

IN ORDER TO COMPLY WITH THE OCCUPATIONAL HEALTH ANDSAFETY ACT AND THE MINE HEALTH AND SAFETY ACT, THE

EMPLOYER SHOULD NOTIFY THE PROVINCIAL EXECUTIVEMANAGER (DEPT LABOUR) OR THE REGIONAL PRINCIPAL

INSPECTOR OF MINES (DME) . SEE ALGORITHM D.

REPORT TO THE COMPENSATION COMMISSIONER WITH COPIES TO THE DEPT LABOUR / DME

NO IMPROVEMENT

1. PHYSIOTHERAPY / CCCUPATIONAL THERAPY

2. RX 3

3. REST / SICK LEAVE FOR 7 DAYS (I)

4. INFILTRATE WITH STEROID INJECTION WHERE INDICATED (J)

1. EXTENDED PERIOD OF REST (I) FOR 1–2 MONTHS (SICK LEAVE AT 75% OF SALARY PAID BYCOMPENSATION COMMISSIONER).

2. CONTINUED PHYSIOTHERAPY AND/OR OCCUPATIONAL THERAPY AND/OR EXERCISE THERAPY, WITH RELAX-ATION, STRETCHING, STRENGTHENING, POSTURE CORRECTION AND GENTLE EXERCISE PLUS

3. REFERRAL TO ORTHOPAEDIC SURGEON FOR POSSIBLE SURGERY PLUS

4. PRE- AND POST-SURGERY REHABILITATION BY OCCUPATIONAL THERAPIST / PHYSIOTHERAPIST /BIOKINETHESIST.

CONTINUED MEDICAL MANAGEMENT

NO / MILD SYMPTOMS ORGREAT IMPROVEMENT

RE-EVALUATE AFTER 7 DAYS

CONSIDER EXTENDING THEPERIOD OF REHABIL ITATION

CONTINUE WITH MEDICAL TREATMENT AS APPROPRIATE (RX 5) AND START WITH COUNSELLING IN CO-OPERATION WITHTHE EMPLOYER’S EMPLOYEE ASSISTANCE PROGRAMME (EAP)

START INDUCTION PROGRAMME AT WORK (K)

IF RECURRENCE OF SYMPTOMS

IF NO RECURRENCE OF SYMPTOMS

NO OR L ITTLE IMPROVEMENTOF SYMPTOMS

CONSIDER PERMANENTALTERNATIVE WORK

PLACEMENT; COMPLETE F INAL MEDICAL REPORT

(W.CL. 302) & DESCRIBEPERMANENT IMPAIRMENT

IF RECURRENCE OF SYMPTOMS

NO SYMPTOMS OR GREATIMPROVEMENT AFTER RX 6

START INDUCTION PROGRAMME AT WORK (K)

CONSIDER PERMANENT ALTERNATIVE PLACEMENT

AND/OR RETURN TO PROPER ADJUSTED WORK

ENVIRONMENT

EVALUATE PROGRESS FOR 2-3 MONTHS

COMPLETE F INAL MEDICALREPORT (W.CL. 302)

NO OR L ITTLE IMPROVEMENT OF SYMPTOMSNO SYMPTOMS OR GREAT IMPROVEMENT AFTER RX 5

CONSIDER PERMANENT ALTERNATIVE PLACEMENT AND/ORRETURN TO PROPER ADJUSTED WORK ENVIRONMENT

i = Rest (i.e. sick leave) should be part of a well-planned rehabilitation programme under the supervision of physiotherapist / occupational therapist / biokinethesist.j = Example: 1 ml Depot Medrol with 2 ml of Lignocaine injected into tendon sheath.k = Return to temporary job for 1-6 months and start with supervised work hardening programme (e.g. with help of ergonomist, physiotherapist, occupational therapist or OHP)

3

2

RX 4

RX 5

RX 6

9. Evaluation of impairment

Should an employee be unable to perform the required

work at the level achieved prior to the development of

this condition, he/she could be deemed ‘unfit’ to con-

tinue in that position, but permanent disability might

not necessarily be awarded, as the Compensation

Commissioner assesses impairment and permanent

disability in comparison with the open labour market

and not for a specific job or position.

When the Final Medical Report (W. Cl. 302) is received

from the treating doctor, after maximum medical

improvement has been reached, impairment will be

determined by the medical officers of the Compensation

Commissioner, in accordance with Internal Instruction

157 for residual impairment of the function of the mus-

cles, tendons, joints or nerves involved.

Maximum medical improvement should preferably be

reached after a reasonable recovery period not exceed-

ing 12 months, and failure to perform work effective-

ly after the following process has been followed:

a. Thorough investigations, which include:

i. Medical assessment

ii. Functional capacity evaluation

iii. Job analysis/ergonomic assessment

b. An integrated treatment plan, which includes:

i. Medical treatment [medication, surgical inter-

vention (where indicated) and / or acute reha-

bilitation (e.g. physiotherapy, occupational

therapy, etc.)]

ii. Vocational rehabilitation, which includes

– Optimising the person’s functional ability

(i.e. ability to perform tasks) through reha-

bilitation that includes work hardening,

work conditioning, etc.

– Addressing problem areas identified in the

job analysis / ergonomic assessment by

allowing alterations in the way in which

work is performed through reasonable

accommodation. Reasonable accommoda-

tion would include workplace environment

adaptation, tool and equipment adaptation,

workstation redesign, job task modification,

retraining and reassignment, and work

schedule modifications.

Permanent disablement will thus be awarded only if

objective and verifiable clinical signs and symptoms

are present after optimum treatment had been admin-

istered, and no further recovery can reasonably be

expected.

In case of nerve conditions, documented abnormal

sensory and/ or motor latencies are important.

Therefore a full sensory evaluation should be

performed. (It is important to note that neural

dysfunction can occur in the absence of abnormal

nerve conduction tests.74)

Grip strength is one of the few objective measura-

ble signs of muscular dysfunction, provided the

measuring instrument is properly calibrated.

Observable muscle wasting is also an objective

sign.

Causalgia and other sensory abnormalities, if accu-

rately and reliably described, will be considered in

the assessment of impairment and disablement.

However, it is expected that most employees will

recover and return to work and that only a very small

percentage will suffer any permanent residual impair-

ment if the worker was properly managed as suggest-

ed in these guidelines.


74 Greening and Lynn (1998)

SECTION C-2:For the employer

CompensationCommissioner

10. Reporting WRULDs to the CompensationCommissioner

Table 21. The following documentation should be submitted to the CompensationCommissioner by the employer individually liable or the mutual association concerned


W. CL. 1 EMPLOYER’S REPORT OF AN OCCUPATIONAL DISEASE OR

W. CL . 305 EMPLOYEE AFFIDAVIT FOR AN OCCUPATIONAL DISEASE (WHEN THE EMPLOYER DOES NOT TIMEOUSLYSUBMIT THE EMPLOYER’S REPORT OF AN OCCUPATIONAL DISEASE (W. CL.1))

W. CL. 14 NOTICE OF AN OCCUPATIONAL DISEASE AND CLAIM FOR COMPENSATION (SIGNED BY THE EMPLOYEE)

W. CL. 110 EXPOSURE HISTORY OR AN APPROPRIATE EMPLOYMENT HISTORY (PLEASE NOTE THAT THE NEW W. CL.110 FORM SHOULD BE USED)

W. CL. 301 FIRST MEDICAL REPORT IN RESPECT OF A WORK-RELATED UPPER LIMB DISORDER (WRULD)WHEN WRULDs ARE REPORTED, W. CL. 301 MUST BE USED INSTEAD OF THE USUAL W. CL. 22 (FIRSTMEDICAL REPORT IN RESPECT OF AN OCCUPATIONAL DISEASE)

ALL OTHER REPORTS THAT MAY BE RELEVANT TO THE DIAGNOSIS AND TREATMENT OF THE CONDITION (E.G. AN ERGONOMICASSESSMENT SUPPORTED BY PHOTOGRAPHS, VIDEO CLIPS, ETC.)

W. CL. 6 RESUMPTION REPORT (EVEN IF THE EMPLOYEE IS AT WORK)

W. CL. 302 PROGRESS/FINAL MEDICAL REPORT IN RESPECT OF A WORK-RELATED UPPER LIMB DISORDER (WRULD)WHEN WRULDs ARE REPORTED, W. CL. 302 MUST BE USED INSTEAD OF THE USUAL W. CL. 26(PROGRESS/FINAL MEDICAL REPORT IN RESPECT OF AN OCCUPATIONAL DISEASE)

As long as the case is open, the employer must submit the following reports on a monthly basis to the Compensation

Commissioner or Mutual Association or employer individually liable, as the case may be, until the employee’s con-

dition has become stabilised, when a Final Medical Report (W.Cl. 302) should be submitted.

12. Claim Processing

The Office of the Compensation Commissioner will

consider and adjudicate upon the liability of all

claims. The medical officers in the Compensation

Commissioner’s office are responsible for the medical

assessment of a claim and for the confirmation of the

acceptance or rejection of a claim.


11. Benefits

Benefits will be payable according to the


Act, 1993, as amended.

11.1 Temporary total disablement

Payment for reasonable temporary total or partial dis-

ablement will be made on the basis of medical reports

for as long as such disablement continues, for a peri-

od not exceeding 24 months.

11.2 Permanent disablement

Permanent disablement will be assessed when a Final

Medical Report is received, after a reasonable recov-

ery period not exceeding 24 months, and failure to

perform work effectively after the appropriate course

of treatment and rehabilitation.

11.3 Medical aid

Medical expenses shall be provided for a period of not

more than 24 months from the date of diagnosis. This

period may be extended if, in the opinion of the

Director General, further medical aid will reduce the

extent of the disablement. The medical aid covers the

costs of diagnosing a WRULD and any necessary treat-

ment provided by any healthcare provider. The

Compensation Commissioner will decide on the need

for, the nature and the sufficiency of the medical aid

supplied.

SECTION D:For the employer

Inspectorate of Labour

13. Reporting to the Inspectorate of Labour

The employer should not only report a case of WRULD

to the Compensation Commissioner, but also to the

nearest Inspectorate of the Department of Labour.

The employer must be able to demonstrate to the

Inspectorate what is being done to reduce the risk of

WRULDs.

The General Administrative Regulations of the

Occupational Health and Safety Act (No 85 of

1993), provides for investigation and recording of

incidents and occupational disease.75

Section 8(1) provides that employers must provide

and maintain a workplace that is safe and without

risk to the health of their employees.

Section 8(2) (d) also provides for a risk assess-

ment of the working environment.

The same is true of section 8(2)(e) dealing with

training of and information to employees.

In discussions with the Chief Inspectorate of Labour

during the drafting of these guidelines, the following

practical steps were tabled by the Inspectorate to

guide employers in adhering to the above-mentioned

requirements (see Algorithm D).

Recommended action steps to prevent,reduce and eliminate WRULDs in theworkplace)


75 Regulations 6 and 8.

STEP 1: NOTIFY THE NEAREST INSPECTORATE OF

LABOUR WITHIN 14 DAYS OF DEFINITIVE

DIAGNOSIS BEING MADE

STEP 2: OBTAIN AN ERGONOMIC ASSESSMENT

STEP 3: COMPILE A SUBSEQUENT PLAN OF ACTION

STEP 4: IMPLEMENT THE PLAN OF ACTION AND

REVIEW IT AT APPROPRIATE INTERVALS

W. CL. 1 EMPLOYER’S REPORT OF AN

OCCUPATIONAL DISEASE OR

W. CL. 305 EMPLOYEE AFFIDAVIT FOR AN

OCCUPATIONAL DISEASE (WHEN THE

EMPLOYER DOES NOT TIMEOUSLY SUBMIT

THE EMPLOYER’S REPORT OF AN

OCCUPATIONAL DISEASE (W. CL.1))

W. CL. 301 FIRST MEDICAL REPORT IN RESPECT OF A

WORK-RELATED UPPER LIMB DISORDER

(WRULD)

W. CL. 302 PROGRESS/FINAL MEDICAL REPORT IN

RESPECT OF A WORK-RELATED UPPER

LIMB DISORDER (WRULD) (MONTHLY)

The improvement of the employee’s working condi-

tions by reducing the ergonomic risks is not only a

legal requirement as stated above, but is also part and

parcel of the employee’s integrated treatment plan

(see p. 41). Determination of impairment is also not

feasible if task and equipment adaptations were not

considered as part of the final report.

STEP 1: Notify the Inspectorate of Labour

The Inspectorate of Labour must be notified within 14

days of definitive diagnosis being made. Copies of the

following forms which was sent to the Compensation

Commissioner, should be sent to the nearest Provincial

Executive Manager of Labour.

STEP 2: Obtain an ergonomic assessment

It is recommended that the employer obtain an

ergonomic assessment of the workplace if WRULD is

diagnosed.

An ergonomics report can only be compiled by an ergono-

mist or one with knowledge of ergonomics and who is

competent to do so – this may be a “safety officer”, an

occupational health practitioner, a physiotherapist, an

occupational therapist or an occupational hygienist.

NOTE:

The Compensation Commissioner will not be liable to pay

for any ergonomic reports.

The costs of ergonomic reports should be carried by

the employer. It is the employer’s responsibility to

assess the health hazards in the workplace according

to the Occupational Health and Safety Act and the

Mine Health and Safety Act.

Therefore employers are required to examine their own

organisation to assess whether other employees are

likely to be at risk of developing WRULDs as a result

of the jobs they do, the environment they work in and

any other organisational factors.

A practical approach to identify and assess risks in

the workplace which may cause WRULDs is discussed

in detail in the next chapter. (See 14, p. 50)

STEP 3: Compile a plan of action

If an ergonomic assessment (see Step 2 above) was

done, the employer should compile a plan of action to

eliminate / reduce the ergonomic risks which may lead

to the development of WRULDs. Such a plan should

have the following elements:

A plan to implement the ergonomic recommenda-

tions (see Step 2 above)

A plan to manage the health surveillance of

employees (see 15, p. 64)

A plan to negotiate a health and safety policy on

the prevention of WRULDs (see 16, p. 67)

The Chief Inspectorate of Labour advises employers to

have such a plan of action ready within 3 months of

the definitive diagnosis being made.

STEP 4: Implement the plan of action andreview it at appropriate intervals

Having adopted a step-by-step approach in identifying

locations in their organisation which have the

potential for WRULDs, as well as identifying those at

risk, employers must now implement appropriate

measures for purposes of prevention and control.

The Chief Inspectorate of Labour advises employers to

implement such a plan of action (see Step 3 above)

and to have the following available within 6 months of

the definitive diagnosis being made:

A review of progress made regarding the

implementation of the ergonomic plan of action,

especially the progress made to adjust/modify the

job to the person and not attempts to fit the

person to the job.

A summary of progress made in the implement-

ation of an occupational health programme

(including a health risk assessment and a medical

surveillance programme).

The negotiated policy on the prevention of WRULDs

signed by the management, labour union represen-

tatives and an occupational health practitioner.


Table 22. Various components of an ergonomic survey

ORGANISATIONALFACTORS

• ORGANISATION OF WORK

• JOB ROTATION

• MANAGEMENT STYLE

• WORK RATE

• MONITORING

• CONSULTATION

• BONUS SYSTEMS

• STRESS, ETC.

ENVIRONMENTAL FACTORS

• COLD TEMPERATURES • VIBRATION, ETC.

TASK ANALYSIS • INDICATE A BRIEF DESCRIPTION OF THE TASK

INDIVIDUALFACTORS

• PHYSICAL CONDITION

• TRAINING

• PERSONAL PROTECTIVE

EQUIPMENT, ETC.

HUMAN – TASKINTERACTION

• USE OF FORCE

• REPETITIVE MOVEMENTS

• RAPID MOVEMENTS

• TWISTING MOVEMENTS

• AWKWARD POSTURES

• OVERSTRETCHING

• LACK OF REST BREAKS

• STATIC LOADING

• DESIGN OF TOOLS AND

EQUIPMENT, ETC.


STEP 1: WITHIN 14 DAYS OF DEFINIT IVE DIAGNOSIS BEING MADE

A COPY OF THE NOTIFICATION OF A WRULD TO THE COMPENSATION COMMISSIONER SHOULD BE SENT TO THEPROVINCIAL EXECUTIVE MANAGER OF LABOUR (OHS ACT) WITHIN 14 DAYS OF THE DIAGNOSIS BEING MADE.

STEP 2: OBTAIN AN ERGONOMIC ASSESSMENT

STEP 3: COMPILE A PLAN OF ACTION

PLAN OF ACTION

OCCUPATIONAL HEALTH PLANSHOULD MAKE PROVISION FOR

EDUCATION, HEALTH RISK ASSESSMENT AND MEDICAL

SURVEILLANCE

NEGOTIATE A POLICY ONPREVENTION OF WRULDs

WITH EMPLOYEES

ERGONOMIC REPORT

• ORGANISATIONAL FACTORS • TASK ANALYSIS • INDIVIDUAL FACTORS • HUMAN – TASK INTERACTION • ENVIRONMENTAL FACTORS

3 REPORT THE FOLLOWING TO THE PROVINCIAL EXECUTIVE MANAGER OF THE DEPARTMENT OF LABOUR

(OCCUPATIONAL HEALTH AND SAFETY ACT)

DETAILED ERGONOMIC PLAN OF ACTION

WITH TIME-SCALE

STEP 4: IMPLEMENT THE PLAN OF ACTION AND REVIEW IT AT APPROPRIATE INTERVALS

THE EMPLOYER WILL SUBMIT A REPORT CONTAINING:

PROGRESS MADE WITH HEALTH RISK ASSESSMENT

AND MEDICAL SURVEILLANCE

THE NEGOTIATED POLICY ON PREVENTION OF WRULDs

A REVIEW ON PROGRESS MADE REGARDING THE

IMPLEMENTATION OF THEERGONOMIC PLAN OF ACTION

D The employer reporting WRULDs to theDepartment of Labour

SECTION E-1For the employer

Ergonomic plan of action

14 A practical approach to identify and assess risksin the workplace which may cause WRULDs

14.1 Ergonomics and its practice

“Ergonomics is the scientific discipline concerned

with the fundamental understanding of interactions

among humans and other elements of a system, and

the profession that applies theory, principles, data

and methods to design in order to optimise human

well-being and overall system performance”.

International Ergonomics Association (IEA) 2000.

Ergonomics is a rigorous, applied science and at an

international level all registered ergonomists must

have at least an MSc in Ergonomics. Often “safety

officers”, occupational health professionals, physio-

therapists, occupational therapists and occupational

hygienists are able to conduct basic ergonomic

surveys or analyses, but not just anyone can offer

ergonomically sound intervention strategies in more

complicated cases. There is a growing number of

guidelines being written for occupational health

professionals on the basic principles of basic

ergonomics, but we urge occupational health profes-

sionals and employers to recognise their limitations

and call in a qualified ergonomist on a regular basis.

Ergonomic enhancements can, and should, play a

major role in furthering the health and safety of

workers and improving the quality and quantity of

productivity. This improved productivity is essential

for the economy of the country and will be achieved

not by the workers being pushed to work harder, but

by running companies on sound ergonomics principles

resulting in improved worker efficiency and less

physical and mental stress being placed on workers.

Physical ergonomics is concerned with human anatomical,

anthropometric, physio-logical and biomechanical

characteristics as they relate to physical activity.

Relevant topics include working postures, materials

handling, repetitive movements, heavy work, work-

related musculo-skeletal disorders, workplace layout,

safety and health.

Cognitive ergonomics is concerned with mental

processes, such as perception, memory, reasoning,

and motor response, as they affect interactions among

humans and other elements of a system. Relevant

topics include mental workload, decision-making,

skilled performance, human-computer interaction,

work stress and training as these may relate to the way

humans work in systems.

Organisational ergonomics is concerned with the

optimisation of socio-technical systems, including

their organisational structures, policies, and processes.

Relevant topics include human system considerations

in communication, human resource management,

work design, design of working times, teamwork,

participatory design, community ergonomics, cooperative

work, new work paradigms, virtual organisations,

tele-work, and quality management. While the emphasis

in any ergonomic investigation may be more in one

domain than the other, it is important to realise that

no thorough evaluation of a work site should ever be

exclusively in one area: a holistic approach is the very

essence of any ergonomic assessment.

With the growing awareness of ergonomics in industrial

developing countries it is important that the limited

number of ergonomists establish a “functional

partnership” with other professionals involved in

addressing the challenging problem of improving the

often horrendous working conditions, as well as the

health and safety of people working under these

conditions.

Ergonomic principles applied systematically will

ensure improved working conditions, thereby reducing

the risks of injuries and illness arising from working

under poor conditions. A prime objective of ergonomics

is to increase worker efficiency and reduce the like-

lihood of excessive physical and/or mental strain

being placed on the worker, thereby improving

productivity, with obvious benefits for workers and the

organisation.

14.2 Ergonomic analysis – practical steps

Changing social attitudes have made most jobs/tasks

non-gender specific. If the person performing a job

has the physical and mental capability to successful-


ly and safely complete the task, by law he/she has the

right to perform that job. Concurrent with these

trends, is the need to develop safe, efficient environ-

ments which allow for adjustability to accommodate

persons of varying physical dimensions and skill

capabilities. When taking into account subject specif-

ic factors like gender, age and cultural background,

the problem of fitting the task to the user becomes

difficult.

The complexity of an ergonomic assessment is limited

only by the physical resources available to the

investigator. Many thorough ergonomic assessments

have been completed with a ruler, weigh scale and

(sometimes) photographic equipment. Although some

of the data reduction is computation intensive, insight

may be gained from easily obtainable information.

An existing job design will as a rule determine:

the types of tasks performed

how tasks are performed

the order in which tasks are completed

the type of equipment needed to complete the task

One must always keep these factors in mind when

assessing a task. Generally, the types of tasks

performed are the only factors which remain fixed.

However, how tasks are performed and the order in

which these tasks are completed, may be factors

which can be adjusted to improve overall task

performance and decrease risk for injury or error.

Although the type of equipment required for the task

is often a fixed variable, suggestions for alterations to

equipment may be necessary, especially if equipment

design is deemed responsible for causing acute or

chronic injury to the worker.

The following criteria have been identified as necessary

for a well-designed job (Stones, 198976):

Allows worker to vary body position to avoid

physical strain

Allows worker to frequently change mental tasks to

avoid mental fatigue

Gives worker a sense of accomplishment

Provides adequate work/rest ratios which allows

the person adequate time to complete the task and

recover in order to continue to the next task

Allows an adjustment period (warm-up) for physi-

cally demanding tasks (habitualise to the working

conditions)

Prompts worker as to what tasks to do and how to

complete them

In order to successfully make recommendations for

improved manners in which a task/skill is to be per-

formed, these criteria should be satisfied. Depending

upon the specific job being considered, some of the

listed criteria will rank higher in importance than oth-

ers. However, the following should be considered: The

ultimate goal of an ergonomic analysis is to ensure

that a person is satisfied physically, psychologically,

and socially with their work situation.

14.3 Principles of task/workplace assessment

14.3.1 Heed concerns of workers and supervisors

The most efficient form of ergonomic assessment is to

ask all individuals (involved in completing a task)

about their specific concerns and suggestions for cor-

recting the situation. Workers involved directly with a

task will as a rule delineate specific problems for the

safe and successful completion of the task.

Management and supervisors will detail specific per-

formance standards expected of the worker.

Performance expectations may be a fixed variable or

one that is presently unacceptable from a human per-

formance point of view.

14.3.2 Gain better understanding of jobs and tasks

For optimal understanding of a job or task, one should

perform it oneself. This may not however always be

feasible, especially where complicated or dangerous

tasks are being assessed. First-hand experience could,

however, be invaluable when assessing a task. In

attempting a skill or job, one must always be aware of

the physical and mental demands involved. For

example, is the task physically reasonable; can the

task be performed for an extended period of time; is

there evidence of physical or mental stress?

Cognisance of these questions allows for better

decision-making on task components to be considered

in greater detail.


76 Stones (1989)

14.3.3 Identify existing and potential hazards

There are several checklist-type surveys which can be

used to organise the assessment of a task. These

checklists are discussed in more detail later in this

chapter. The scope of an ergonomic assessment is

generally limited to specific or potential hazards.

14.3.4 Determine underlying causes of hazards

Use the Ergomax’s (Pty) Ltd. checklist (see 14.7 –

14.10) to determine factors contributing to a claimed

WRULD. The total score will enable one to determine

potential risk and the area/s which are deemed high risk.

14.4 Recommend changes and monitor hazard controls (personal protectiveequipment, engineering controls, policies, procedures)

Once causal factors have been identified, they should

be monitored on at least a weekly basis. If changes

have been done, it is important that these changes be

monitored and assessed.

14.5 Workplace observation considerations

The first inspection of a worksite or task will provide

one with basic information for initiating a more

comprehensive ergonomic assessment. It should be

kept in mind that a worker may alter work habits or

execution of skills if there is any suspicion of being

observed. Observations should be as discreet as

possible and if management and employees agree, a

video or still photography record could be obtained

(this process could be sensitive, particularly when

workers’ union or management policies are

considered).

The following has been adapted from Stewart (1989)77

and is based on the U.S.A. National Safety Council’s

report on poor common working practices. These

include items to be noted on initial inspection, more

specifically for an industrial setting.

Using equipment without authority or previous

instruction/certification

Operating at unsafe speeds, rates or repetitions

Removing guards or other safety devices, or

rendering them ineffective

Using hands or body instead of tools or push sticks

Overloading, crowding or failing to balance

materials, or handling materials in other unsafe

ways, including improper lifting techniques

Repairing or adjusting equipment which are in

motion, under pressure, or electrically charged

Failing to use or maintain, or improperly using

personal protective equipment or safety devices

Creating unsafe, unsanitary or unhealthy

conditions by improper personal hygiene, by using

compressed air for cleaning clothes, by poor

housekeeping, or by smoking in unauthorised areas

Standing or working under suspended loads,

scaffolds, shafts or open hatches

14.6 Assessing working environment forWRULDs

Many employers find a checklist useful in deciding:

If other employees are at risk of developing

WRULDs

Whether they need to take more precautions; and

What to do.

Following a step-by-step approach in assessing

potential WRULDs in their organisation and identify-

ing those at possible risk, employers must implement

the appropriate measures needed to prevent or control

the risk of WRULDs:

Useful checklists are supplied with kind permission of

the Health and Safety Executive (HSE) in the United

Kingdom. One does not need any specialist knowledge

to complete these. “Yes” entries in the checklist imply

that action is required. The more “Yes” entries, the

more urgently one should act. Risks may be much

higher than average where several things are present in

the same job which may cause WRULDs.

14.6.1 Ergomax risk calculator

Ergomax (Pty) Ltd developed a WRULDs risk

calculator which could be used to assess and score

(as percentage) the critical ergonomics risk factors

an employee is exposed to (Kennedy 2004)78


77 Stewart (1989) 78 Kennedy (2004)

http://www.ergomax.co.za


(see 14.7 – 14.10). The calculator may also be used

as a preventative tool in assessing various workstation

tasks.

In situations where only one risk factor can be

identified, a more in-depth ergonomic assessment of

that particular risk factor is required. The calculator

may score the one risk as low and not give a true

reflection of the severity of the risk. Although one

isolated factor is rarely evident, the likelihood should

nevertheless be considered.

Ergomax’s risk calculator is available on their website:

http:\\www.ergomax.co.za. It can also be done manu-

ally on the following page.

14.6.2 Using the risk calculator

The Total WRULDs Risk Score (TWRS) is obtained by

adding the score for each Task Risk Score (TRS) and

each Human Risk Score (HRS) and multiplying this by

50 to get a percentage score. The following formula

can thus be used:


79 Kennedy (2004) 80 Kilbom (1994)

The task risks discussed below score as either:

TWRS = 50 X [(TRS / 36) + (HRS / 18)]

T W R S = T O TA L W R U L D s R I S K S C O R E A S

P E R C E N TA G E

T R S = T O TA L TA S K R I S K S C O R E ( A D D T O G E T H E R

A L L 9 TA S K R I S K S )

H R S = T O TA L H U M A N R I S K S C O R E ( A D D

T O G E T H E R A L L H U M A N R I S K S )

Any score above 30% is deemed to predispose the

employee to WRULDs.

One can then review the risk data sheet and deter-

mine where the greater risks are. Obviously factors

such as age and gender cannot be adjusted for. The

variables relevant to these human factors need there-

fore to be modified (Kennedy 2004)79.

14.7 TASK RISKS

In Circular Instruction 180 various risk factors are

mentioned that could contribute to the development

of WRULDs. In this section these task risk factors are

defined and practical tools are suggested on how

these task risks could be assessed and scored.

1 = L O W R I S K

2 = M E D I U M R I S K

4 = H I G H R I S K

Note: if a risk is not present, the score is 0

If there is immediate danger, shut down and “lock

out” any hazardous items which cannot be brought to

a safe operating standard until repaired.

14.7.1 Highly repetitive movements

Repetition is a matter of definition (“more than once

per time unit”) and what is low or high depends on

the specific activities or body part involved.

A concern is that in numerically describing the

frequency of an activity one presumes that the actions

occur at regular intervals during the recording time.

Yet, in reality, this is commonly not the case for an

average working day: certain activities may run

concurrently during some periods and may seldomly

occur during others.

Ergomax’s risk calculator is based on data published

by Kilbom (1994)80. Both the number of hand manip-

ulations per 8-hour work shift and the task cycle time

have been used to rate this factor. Task cycle times of

30 sec or less were defined as high repetition; cycle

times greater than 30 sec as low repetition. For hand

manipulations, high repetitiveness was described as

more than 20,000 manipulations per 8-hour work

shift; medium repetitiveness as between 10,000 and

20,000 manipulations per 8-hour work shift, and low

repetitiveness as less than 10,000 manipulations per

8-hour work shift.

These guidelines also consider other areas of the

upper extremity. Each area may have a different abil-

ity to tolerate repetitious activity. At the same rate of

repetitions some specific acts such as pinching may

be less well tolerated than others. This is an example

of complexities that current guidelines may not

address adequately.


Repetition calculator: highly repetitive movements

How often does the repetition occur during an 8-hour

shift or per minute? (Count the number of upper limb

movements the employee makes in one minute)

Ergonomic solutions for force

To reduce the risk of injury, design tasks that min-

imise stress on the body:

Use rollers to move objects

Use mechanical lifting aids

Use two or more people to help lift or move heavy

loads

Use hand carts or dollies with large diameter

wheels for moving objects

If possible use larger muscle groups to complete

the task

14.7.3 Movements at the extremes of reach

Extreme reach is defined as the working area that

occurs outside of your wrist, elbow or shoulder cir-

cumference zone.

For example, if you were to sit at a desk with your

upper arms relaxed and your elbows bent at 90

degrees and you move your forearms in a semi-circle

(like windscreen wipers of a car) that would be your

zone of convenient reach. Obviously this applies in

both the horizontal and vertical directions.

Movements at the extremes of reach predispose the

employee to arm injury due to the static nature the

shoulder muscles have to endure to hold the arm in an

extended position. Furthermore, the further one

reaches, the more the facet joints of the vertebral

bodies are loaded. This increases the shearing forces

within the spine and in turn stresses the surrounding

soft tissue which may result in neck and lower back

pain.

Reach risk calculator: extremes of reach

How far from the centre of the hip to the centre of the

object does the movement occur?

(Measure the distance from the middle of the hip joint


SCORE LOW MEDIUM HIGH(1 POINT) (2 POINTS) (4 POINTS)

REPETITIONS <10,000 10,001 – >20,001PER 8-HOUR SHIFT 20,000

OR OR OR OR

REPETITIONS 20 – 30 31 – 41 >41PER MINUTE

Ergonomic solutions for repetitiveness

Repetitive motions can have cumulative effects. To

reduce the risk of injury, perform tasks so as to min-

imise stress on the body:

Implement frequent short rest breaks

Minimise the number of motions between opera-

tions

Use conveyors, chutes, slides and turntables to

change direction of material flow

Prevent movements occurring at the extreme range

of motions

14.7.2 Movements requiring force

Force is defined as any muscular contraction that

requires extended effort over a given time period.

Forcefulness is also a matter of definition and what is

low or high depends on the specific activities or body

part involved. Not everyone has the ability to measure

force as this is often expensive. For the purpose of

these guidelines any force exerted over an extended

time period places the employee at risk.

Force risk calculator: movements requiring force

How long does the forceful movement last during an

8-hour shift?

(Time the duration of the movement, for example if

one has to turn a screwdriver for half and hour every

hour, then the total risk for this category would be 4

hours or 240 minutes)


EXERTION OF FORCE PER MINUTE PER 8-HOUR SHIFT 1-120 121- 240 >240

to the middle of the object being manipulated)


Static muscle risk calculator

How long is the static posture held?

(Time the duration the employee has to hold his arms

above his head, for example if one has to turn a

screwdriver for half and hour above one’s head, every



Ergonomic solutions for reach

Keep working zones within “safe working parame-

ter” (see diagrams in section 14.9, p. 55)

Avoid obstacles which necessitate employees lean-

ing over in order to reach controls

Place objects used most frequently within safe

working zones

14.7.4 Static muscle loading

Static postures may be defined as postures that are

held for longer than 30 seconds, without the limb

moving.

Fixed postures also result in static (isometric) muscle

contractions. A muscle that is actively involved in

concentric and eccentric contractions converts glu-

cose and oxygen into carbon dioxide and water, liber-

ating energy in the process. Muscles therefore require

a regular blood supply in order to replenish fuel and

remove waste products. The rhythmic pumping action

of an active muscle facilitates this flow of blood.

However, during sustained isometric contractions a

muscle occludes the blood vessels within it, resulting

in diminished blood supply. The muscle is thus

starved of oxygen and waste products accumulate as

oxygen-independent metabolic processes take place.

Discomfort and fatigue occur rapidly for this reason,

as well as the increased risk of WRULDs.

For example, if one has to fit a light bulb above your

head, you would have to hold your arms above your

head continually in order to position and screw in the

bulb. This results in a static muscle posture of the

shoulder muscles and fatigue sets in quickly.

Ergonomic solutions for static muscle loading

Try avoiding the static posture where possible

Allow lifting devices, jigs or turntables to hold and

move the load whilst handling it

Increase the number of rest breaks

14.7.5 Awkward sustained postures

Postures that are not within the normal reach zones of

the employee are considered to be awkward.

This variable needs to be measured individually for each

employee assessed, as we all have various working

postures. The time spent working in this posture will

need to be considered to calculate the risk exposure.

For example, if one has to fully bend one’s wrist in

order to thread material through a sewing machine,

this wrist posture will be deemed awkward.

Risk calculator: awkward postures

How long is the awkward posture maintained?

(Time the duration the employee has to hold his hands

in an awkward position, for example if one has to turn

a screwdriver for half and hour, with hand bent every




MEASUREMENT IS 150 – -599 600 – 750 >750 MMTAKEN FROM THE MM MMPERPENDICULAR DISTANCE BETWEEN THE CENTRES OF THE HIP TO CENTRE OF THE OBJECT BEING LIFTED (MILLIMETRES)


MINUTES PER 8-HOUR SHIFT 1-120 121-240 >240



Ergonomic solution for awkward postures

Keep working zones within “safe working parame-

ter” (see diagrams in section 14.9, p. 55)

Avoid obstacles which necessitate employees lean-

ing over in order to stretch and reach controls

Design hand-held tools to accommodate the angle

of use, instead of the employee having to bend his

wrist, for example

14.7.6 Contact stress

Contact stress is defined as the time spent leaning/

pressing the upper limb against an uncomfortable

surface (e.g. uncomfortable gripping and twisting,

sharp edges to hand tools, desk edges, etc.)

The risk calculator considers the time spent in con-

tact with the object. For example, if one leans one’s

elbows on the desk all day to type, the contact stress

for the elbows will be considered a high risk

Contact stress calculator

How long is contact made with an object?

(For example: Time how long the employee has to lean

his hand against his desk in order to type)


Ergonomic solutions for contact stress

Avoid employees having to lean against objects or

machinery

Design appropriate surface edges for employee to

work against. (Round square edges)

Proven adequate Personal Protective Equipment

(PPE) for employees who have to hold tools for

extended periods

14.7.7 Vibration

Vibration is defined as any hand-held tool or working

surface that shakes, pulsates whilst in use.

The calculation of vibration exposure is often costly

and difficult to administer. For ease of use, Ergomax

uses length of time exposure to vibrations. Obviously

exposure limits will vary according to the area of the

body affected and the frequency of vibrating cycles

per second exposure. Vibration exposure can affect

your upper limbs when using hand-held power tools,

hand-guided tools or holding material being processed

by machinery.

Vibration risk exposure

How long is the employee exposed to vibrations?

(Time how long the employee has to stand or use

vibrating equipment.)





Ergonomic solution for vibration

Minimise exposure to vibrations from hand-held

tools.

Consider using anti-vibration gloves when using

vibrating tools

Maintain tools regularly

Vibration exposure

Note: the best way to quantify vibration exposure is to

calculate the daily vibration exposure. This, however,

is often difficult, as suppliers often do not indicate

the vibration magnitude. The vibration exposure is

dependant on the duration of exposure to a reference

period of 8 hours, thereby allowing different expo-

sures to be compared. It is currently recommended

that preventative measures and health surveillance be

provided when workers’ daily vibration exposure regu-

larly exceeds 2.8m/s2 A(*8).

It is possible to calculate the vibration exposure when

the vibration magnitude of the tool is known. For

example, information from a supplier of a chainsaw

states that vibration magnitude is 9.7 m/s2. The

equipment is used for 2 hours daily.

Using A(8) = ahw√t/8

where: t is the daily exposure time; ahw is the vibration

magnitude

A(8) = 9.7√2/8

Average for 8 hours = 4. 8m/s2

14.7.8 Load exposure

Load is defined as the weight of the object being lifted.

Obviously, the heavier the load, the more strenuous

and dangerous the task. The introduction of mechan-

ical devices for handling heavy materials, the division

of heavy items into smaller objects or two workers

involved in handling one heavy item reduces the

fatigue caused by handling heavy weights, and worker

productivity is improved. The risk of back injuries is

also greatly reduced.

Load risk calculator

What is the weight of the load lifted or handled?

(Weigh the tool or load that the employee has to

operate or lift)



KILOGRAM < 5KG 5,1 – 7 KG >7KG



Ergonomic solutions for load

Minimise the load as far as reasonably possible

Lift loads within safe range of motion zones

Lift directly in front of the body

Eliminate or reduce lifts occurring in confined

spaces

Decrease frequency of lift

14.7.9 Cold exposure

Cold is defined as the environment temperature being

below 18 degrees Celsius where discomfort is felt.

In general, when it is too cold, or when we touch cold

materials, our hands can become numb. Due to the

physiological changes that occur due to cold expo-

sure, one is more likely to misjudge the amount of

force required to complete work and normally exert

too much force. A cold environment also makes our

bodies less flexible. Every movement made and every

position held takes more effort.

Cold risk calculator

How long does the employee spend working in a cold

environment?

(Time the length of shift the employee is working in a

cold environment)

Ergonomic solutions for cold environments

Minimise the exposure to cold environments as far

as reasonably possible

Allow adequate personal protective equipment

against the cold.

14.8 Additional guidelines to WRULDs assessment

a.) Do not operate equipment unless authorised to do

so. Ask the operator for a demonstration. If the

operator of any piece of equipment does not know

what dangers may be present, this is cause for con-

cern. Never ignore any item because you do not

have the necessary knowledge to make an accurate

judgement of safety.

b.) Look up, down, around and inside. Be methodical

and thorough. Do not spoil your limited inspection

opportunities with a “once-over-lightly” approach.

c.) Clearly describe each hazard and its exact location

in your rough notes. Allow recording of all findings

before they are forgotten or inspection is interrupted.

d.) Ask questions, but do not unnecessarily disrupt

work activities. This may interfere with efficient

assessment of the job function and may also create

a potentially hazardous situation.

e.) Consider the static and dynamic conditions of the

item you are inspecting. If a machine is shut

down, consider postponing the inspection until it

is functioning again.

f.) Discuss as a group: ‘Can any problem, hazard or

accident generate from this situation when looking

at the equipment, the process or the environment?’

Determine appropriate corrections or controls.

14.9 Ergonomic range of motion with safeworking zones

The following sketches may be used as a quick

reference to describe safe working zones for various

movements of the upper limb. Any movements

occurring outside the “safe working zone” is deemed

awkward and should be avoided where possible.

14.9.1 Wrist range of motion:81

Flexion/ Extension


81 Drawings and diagrams taken from Luttgens, K. & Hamilton, N. (1997).

Kinesiology: Scientific Basis of Human Motion, 9th Ed., Madison, WI: Brown

& Benchmark.

00 degrees neutral

500

Flexion

Safe working zone

Hyper extension

600

1800

1400

900

Safeworking

zone

00

Neutral

100 or lessHyper extension

Flexion

900

Safe working zone

00 Neutral

Inward rotation (internal)

Outward rotation (external)

900

900

900

500Safe working zone

00 Neutral

900

1800

Hyper extension

Forw

ard

flexi

on

14.9.2 Elbow range of motion

Elbow flexion extension

Radial and ulnar flexion

900

200

Safeworking

Neutral00

300

Radialflexion

Ulnarflexion

900

14.9. Shoulder range of motion

Internal and external rotation

Note: any work occurring above shoulder height is

deemed awkward for the purpose of these guidelines.

Shoulder flexion extension

14.10 Human risks – Human variables affecting WRULDs risk exposure

The human risks discussed below score slightly

differently than the task risks as each human risk has

independent associated risks:

14.10.1 Gender

Depending on one’s gender, the exposure or likelihood

of the development of WRULDs varies. Due to physio-

logical differences, females appear to be more predis-

posed to certain WRULDs relative to their male coun-

terparts. Use the table below to score the relevant

risk.

For female employees add a score of 2 to the total

human variable score.

14.10.2 Age

As one ages certain physiological and biomechanical

changes occur. For example one looses 1 percent of

one’s total strength capability each year from the age

of 25 onwards. These physiological changes,

associated with ageing, may increase the likelihood of

developing WRULDs in certain individuals.



AGE (YEARS) 20-39 40-50 >51


AGE (YEARS) 19-27 28-32 >32

SCORE LOW MEDIUM HIGH(3 POINTS) (5 POINTS) (7 POINTS)

PERIOD (YEARS) <2 2-5 >5

14.10.3 Body mass index (BMI)

Body mass index (BMI) is derived from the calculation

of body mass divided by height squared.

BMI = kg/m2

Body mass index can be used to indicate whether one

is overweight, obese, underweight or normal. It will,

however, overestimate fatness in people who are mus-

cular or athletic. One generally makes use of the BMI

index as a quick reference to the body composition of

an individual, instead of the lengthy process of meas-

uring ones fat content versus lean body mass. Women

will tend to score higher due to the physiological con-

stitution of their bodies.

14.10.4 Exposure history

Exposure history considers the environment in which

the employee has worked that have exposed him/her

to the risk factors of WRULDs. If the employee has

worked in an environment which has previously

exposed him/her to any of the seven task risk factors,

indicate the length of time he/she has been exposed.

14.11 Worked examples:

14.11.1 Industrial setting

An employee in a warehouse has to lift and place

more than 480 boxes on a conveyor belt above shoul-

der height each hour. The duration of the shift is eight

hours and the employee is required to complete this

task for the entire shift. The conveyor system is 1.8 m

above the ground. Each box is held briefly (3 sec)

whilst the conveyor partitioning moves into place in

order for the employee to load the box.

Task criteria:

Lifts occur 8 times per minute

Movements requiring force is throughout the shift

Static posture is held for 24 sec per minute

Awkward postures occur throughout the shift

Contact stress occurs for 36 sec per minute

The weight of the load is 8 kg

The distance that the box has to be moved is

1.8 m

There is no vibration exposure

Human criteria

The employee’s age is 42 yrs, is a female and has

been exposed to one or more of the seven risk fac-

tors for approximately 5 years. Her height is 1.61

and weight is 74 kg.

BMI = 74/1.61m2

= 74/2.592

Total WRULDs Risk Score:

TWRS = 50 X [(TRS / 32) + (HRS / 18)]

= 50 X [(18/32) + (12/18)]

= 50 X [0.5625 +0.6666]

= 50 X 1.2291

= 61.45 %

14.11.2 Office setting

An employee is involved in editing magazine articles

and spends about 5 hours a day typing. She is 53

years old; height 168 m and weight is 63kg. Her

keyboard is placed 45 cm from the centre of her hip.

She has to hold her arms up in order to type on her

keyboard, due to the height of the desk. As a

consequence she has to rest her elbows on the edge of

her desk. She makes over 100 repetitions with her

fingers each minute. She has been at this job her

whole working career.

Task criteria:

Repetitive movements occur more than 100 times

per minute

She types for 5 hours a day (force)

Her keyboard is placed 450 mm from the centre of

her hip (reach)

Her shoulder muscles have to hold her arms up

whilst typing (static)

She rests her elbows on the desk whilst typing

(contact)

Human criteria

The employee’s age is 53 yrs, is a female. Her

height is 1.68 m and weight is 63 kg.

BMI = 63/1.68m2

= 63/2.8224

= 22.3

Total WRULDs Risk Score:

TWRS = 50 X [(TRS / 32) + (HRS / 18)]

= 50 X [(22/32) + (13/18)]

= 50 X [0.6875 +0.7222]

= 50 X 1.409

= 70.46 %

14.12 Ergonomic intervention strategies

14.12.1 Deciding how to reduce risks

Approaches to problems can include people-based

solutions (e.g. training, adding variety to the job,

appropriate treatment of the individual and reschedul-

ing rest breaks) as well as alterations to workstations,

tools or the work environment. However, no single

approach is successful all the time and as such,

several solutions need to be investigated.

Often straightforward and inexpensive changes are all

that is required. Again, remember to consult the

workers who are actually doing the job. They should

know what the difficulties are and may have good

ideas on how to modify the task.

Unusual WRULDs problems may require more

complex solutions, for example where risks are high,

or where several interacting risk factors exist. Here,

approaches such as redesigning workstations,

providing better tools, or supplying sub-components

already assembled may help. If not, one may have to

consider fundamental changes of approach such as

automation, or changing from assembly-line to other

production methods. One could also consider intro-

ducing job rotation – which implies workers in a team

exchanging jobs at intervals to provide greater variety.

Remember, if one introduces new tools, equipment or

working methods, workers will have to be trained in

order to get the best results (both for health and

safety, as well as productivity).

An employer should make sure that staff knows who is

Page | 60 | of pages© 2004 | Compensation Commissioner’s Guidelines for Health Practitioners and Employers to manage WRULDs | Version 1.0

responsible for taking action to reduce the risks for

WRULDs.

14.12.2 Ergonomic principles

The following main ergonomic principles must be

taken into consideration when implementing an

ergonomic plan of action

a) Avoid the risk altogether (e.g. by not using a par-

ticular tool or process)

b) Combat risks at source rather than applying pallia-

tive measures

c) Adapt work to the individual, especially as regards

the design of workplaces, the choice of work

equipment and the choice of working and produc-

tion methods, with a view to eliminating monoto-

nous work and work at a predetermined rate

d) Take advantage of technological and technical

progress to improve working methods and make

them safer

e) Ensure that the measures form part of a coherent

policy of reducing risks, which takes account of

the way work is organised, working conditions, the

working environment and any relevant social fac-

tors

f) Give priority to measures which protect the whole

workforce

g) Ensure that workers understand what they need to

do by providing information and training

h) Ensure an active health and safety culture

throughout the entire workplace

i) Conduct regular evaluations of the situation in

order to be pro-active to potential problems


Table 23. Some of the main measures that employers can take to prevent WRULDs

A qualified ergonomist can be of great value in providing expertise and advice so that WRULDs can be eliminated

from the workplace:

Improving the work environment Improving task and equipment design


THE PHYSICAL WORK ENVIRONMENT CAN BE A SOURCEOF STRESS AND STRAIN TO WORKERS. EMPLOYERSCAN HELP TO REDUCE THESE STRESSES BY:

a ) Ensur ing no ise leve ls a re kept as low as poss ib le .

b ) Improv ing l i gh t ing leve ls and remov ing i r r i ta t ingf l i cke rs o r g la res .

c ) Improv ing tempera tu re and vent i l a t ion .

d ) Prov id ing we l l des igned pro tec t i ve c lo th ing and reg -u la r b reaks in a warmer env i ronment fo r worke rswho have to work in co ld cond i t ions o r w i th f rozenfoods .

e ) P rov id ing su i tab le res t a reas away f rom the works ta -t ion fo r worke rs to have recupera t i ve b reaks .

f ) Encourag ing f lu id in take a t a l l t imes but pa r t icu la r -l y in hot env i ronments .

g ) Reduc ing the need to use v ib ra t ing too ls .

h ) P rov id ing v ib ra t ion absorb ing g r ips on too ls and bymainta in ing them in a good s ta te o f repa i r.

THIS CAN BE DONE BY APPLYING GOOD ERGONOMIC PRINCI-PLES IN THE DESIGN OF TOOLS, EQUIPMENT, WORKSTA-TIONS, TASKS AND WORK METHODS. IMPROVEMENTS CANBE ACHIEVED BY:

a) Selecting tools and equipment appropriate for the job andsuitable for the individual who has to use them.

b) Maintaining tools in a condition which makes them easy touse, e.g. keeping them sharpened or lubricated.

c) Providing powered versions of tools.

d) Selecting tools with handles which allow the worker to workwith the limbs in a ‘natural’ alignment.

e) Redesigning workstation so that everything is within reach,or so that controls are easier to use.

f) Providing seats, equipment, etc., that can be adjusted tomeet individual needs and by providing training in how toadjust them.

g) Giving the worker an appropriate space in which to work.

h) Redesigning the task to minimise repetitive movements andstatic handling and/or sustained postures.

i) Automating the task.

j) Redesigning the work method to avoid overreaching andother awkward postures.

Improving work organisation Taking account of the individual

WORK SHOULD BE ORGANISED IN SUCH A WAY THATEMPLOYEES’ HEALTH AND SAFETY IS NOT PUT AT RISK.WORK ORGANISATION CAN BE IMPROVED IN A NUMBER OFWAYS, FOR EXAMPLE BY:

a) Improving communication between management and staff.

b) Consulting employees and their representatives about theirjobs and any changes they may suggest (participatoryergonomics).

c) Ensuring that jobs which pose a risk and which cannot becompletely eliminated are rotated so that no individualspends long periods on that task.

d) Ensuring that all employees have sufficient variety in thedemands of their task, thus ensuring different muscles andpostures being utilised and making their jobs more satisfying.

e) Providing adequate rest breaks with pause exercises to prevent the build-up of fatigue, and by ensuring that thebreaks are in fact taken, i.e. improving the work-to-restratio.

f) Identifying and limiting stress factors in the workplace.

g) Discussing the control of work pace and the overall plan forthe day with the workers.

h) Removing task rate and payment by results systems thatmake earnings dependent on excessive work rates.

i) Removing bonus, performance or monitoring schemes whichmake workers push themselves beyond their capacities.

j) Having proper monitoring and reporting procedures forsymptoms of WRULDs as well as appropriate work harden-ing programmes.

EMPLOYERS NEED TO ENSURE THAT WORKERS ARE NOT ATRISK THROUGH LACK OF TRAINING OR BECAUSE OF INDIVIDUAL FACTORS. THEY CAN HELP PROTECT THEIREMPLOYEES FROM DEVELOPING WRULDs BY:

a) Providing information and training about WRULDs and howto recognise the symptoms.

b) Providing information and training about how to avoidWRULDs through safe working techniques and safe workingpostures.

c) Advising employees on the importance of taking breaksbefore the onset of fatigue and of varying their work routines.

d) Informing employees of the importance of reporting symptoms of WRULDs as soon as possible.

e) Providing information on how to report symptoms ofWRULDs.

f) Ensuring that workstations and equipment can be fullyadjusted to accommodate people of very different sizes,heights or with particular needs.

g) Ensuring that workstations and equipment can be adjustedto the needs of people with disabilities.

h) Ensuring that males or females, left or right-handed work-ers, do not have to use equipment and tools designed forother groups.

i) Ensuring that new employees or those returning from a longbreak are allowed to build up their work rate gradually.

j) Ensuring that the wearing of personal protective equipmentor clothing (e.g. gloves) does not increase the risk ofWRULDs.

Care should be taken that this does not result in an over-eager-ness to report WRULDs in the hope of receiving compensation.

SECTION E-2FOR THE EMPLOYER

Occupational healthprogramme

15 Occupational health programme


Figure 9. Early detection andprevention of WRULDs

COM

PEN

SATI

ONIS

M

Early detection and prevention of WRULDs are very important – Koemar (1994) described early signs of WRULDs as the ‘fog’ slumbering in the valley in front of

the mountain! The ‘fog’ may partly obscure a volcano of WRULDs ready to explode!

Disability

Disorders, injuriesand diseases

requiring medical interventions

Pronounced symptoms make itdifficult to continue usual

activities

Soreness, pain, persistent aches and painsaffect well-being and performance

Occasional movement or posture problems, intermittent discomfort, fatigue, small aches

Fatigue and tiredness, uneasiness and discomfort generally considered ‘normal’ after a full day’s work

VERSUS PREVEN

TIONISM

Health risk assessment, adequate medical surveillance

and relevant health education and training should

form an integral part of an institution’s occupational

health programme.

15.1 Health risk assessment

As part of risk assessment, employers should check

whether any of their employees are already displaying

symptoms of WRULDs. However, it is important to

note that:

Many employees may not recognise their own

symptoms as WRULDs.

Many employees will be unaware of the serious

nature of WRULDs even if they do suspect the

symptoms.

Many employees will continue to work, regardless

of their symptoms.

Many employees will be unaware of the importance

of reporting their symptoms early.

Many employees will be afraid to report their

symptoms.

Early detection and prevention of WRULDs (Figure 9)

are very important. It is important to be on the look-out

for the ‘fog’ – the level of which indicates perception

and awareness of symptoms. The fog may partly

obscure a volcano of WRULDs ready to explode!82

Employers should take account of these problems

when trying to assess the extent of any existing

problem in their organisation.

One way to find out whether employees have WRULD

symptoms is for employers to look at their accident

book and at sickness absence records and to consult

their occupational health service if one is available.

However, since many employees will not recognise or

report symptoms, as already indicated, employers will

probably need to carry out a health survey of their

employees. This should be done in an open and trans-

parent way and employers will need to explain the pur-

pose of the survey and demonstrate a commitment to

resolving any problems, whilst guaranteeing employ-

ment security to anyone found to have symptoms. If

employees suspect that the real motive behind the

survey is to weed out people with problems, they will

82 Koemer (1994)

not have any confidence in the survey and are unlikely

to take part.

The survey itself will have to be appropriate to the

purpose and set out in a way that is easy to understand.

The language used should be simple, with translations

available in any other languages in common use

amongst the workforce. (See 15.1.1, p. 65) An example

of a simple form which incorporates questions about

symptoms with reference to different parts of the body

as well as questions about the job can be viewed on

the next page.

The role of trade unions is vital in ensuring that

surveys are done properly and are not used to weaken

job security and discriminate against employees. The

employer should consult the union at every step along

the way and obtain agreement for the method to be

employed.

15.1.1 Medical surveillance

Health surveillance can play an important role in the

prevention of WRULDs, by detecting symptoms early,

so that remedial action can be taken. It should be seen

as an essential backup to the preventive measures

taken to design WRULDs out of the workplace.

Employers should at the very least set up an internal

reporting system so that symptoms of WRULDs can be

monitored, recognised early, and treated before the

condition progresses to a more serious state. In order

for such a system to be effective, it must be explained

properly to employees so that they understand the

purpose of the system, how to recognise symptoms of

WRULDs, how to report them and what would happen

if they do report them. Employees are unlikely to

report symptoms if they think their future employment

will be at risk, so the system must be seen as a

positive element of the employer’s approach to

WRULDs prevention.

Some employers have tried to introduce pre-

employment screening in an attempt to weed out

people who may be susceptible to WRULDs. Not only

could this amount to discrimination under the law, but

the evidence shows that there is no reliable test

available. There is no scientific evidence to show that

pre-employment and preplacement screening can

predict the risk of developing a work-related musculo-

skeletal disorder. The principle must be to make the

workplace safe for everyone and not to try and select

a workforce of super-resilient men and women.

The Musculo-skeletal Wellness Questionnaire

(currently only available in English and Afrikaans) can

help you assess / screen potential WRULDs in the

workplace.

More detailed scientific musculo-skeletal questionnaires

are available for occupational health practitioners and

ergonomists, e.g. the Nordic Questionnaire which has

been adapted by the CSIR for the South African

mining industry.


SECTION E-3For the employer

A policy on the prevention and

management of WRULDs

16 Negotiate a policy on the prevention and management of WRULDs

It is recommended that an employer negotiate a poli-

cy on the prevention and management of WRULDs.

This negotiated policy could be signed by the manage-

ment, health and safety committee representatives,

labour union representatives and an occupational

health practitioner.

The Trade Union Congress in the United Kingdom

(TUC) has published a model policy on the prevention

of WRULDs, which has been adapted with their kind

permission. As with all model policies, it is not some-

thing merely to be accepted and filed away, but

should be discussed, fully understood and adapted as

a living policy. This means that if such a policy is

introduced, the health and safety committee should

monitor its implementation and effectiveness.

The following model policy for the prevention and

management of WRULDs could be used as an example

by employers when developing their own custom-made

policy, which should be relevant for their own unique

circumstances:83

16.1 Aim

The aim of this agreement is to provide a healthy and

safe working environment and prevent the develop-

ment of WRULDs. The employer and the union recog-

nise that there must be a programme of preventive

action which should include the following commit-

ments:

a.) Management commitment to reduce the risk of

WRULDs.

b.) To consult the union on the development of the

programme.

c.) To provide resources for the information, instruc-

tion and training to be given to management, those

involved in design of work areas, supervisors and

employees on WRULD, its symptoms and its pre-

vention.

d.) To conduct risk assessments for tasks identified as

potentially hazardous by agreement with manage-

ment and the union, or subsequently through a

regular programme covering every aspect of work,

or in the event of significant changes to work

systems, work methods, equipment, environment

or training.

e.) To set up a competent Health and Safety working

group on WRULDs to oversee the implementation

of the WRULD prevention policy.

f.) To implement changes identified as necessary by

such risk assessments and review the implementa-

tion of these changes (e.g. an agreement on suit-

able rest breaks and pause exercises when neces-

sary during continuous repetitive work (dependent

on the intensity of the work).

g.) Clear procedures for early reporting of symptoms

and no victimisation or harassing of employees

who develop WRULDs or report symptoms.

h.) Clear procedures for dealing with diagnosed cases.

i.) An agreement that employees with WRULD symp-

toms will be offered temporary or permanent rede-

ployment and/or time off for recovery, as stated in

the Compensation for Occupational Injuries and

Diseases Act.

j.) An agreement that the employer will pay for any

reasonable treatment or investigations that are

required until the case is accepted by the

Compensation Commissioner, when these expenses

can be claimed from the Commissioner.

k.) To use an agreed occupational health practitioner

experienced in WRULDs to monitor staff on a

regular basis.

l.) A commitment to monitor and review the policy.

16.2 Risk assessments

The following factors which are known to cause or

contribute to WRULDs will be taken into account, in

terms of work equipment, workplaces and methods:

a) Frequency and duration of repetitive movements.

b) Force used in performing the movements.


83 Used and adapted with the kind permission of the London Hazard Centre.

c) Absence of adequate recuperative breaks.

d) Awkward postures, particularly degree of fixed

muscle loading in the trunk, shoulders and arms.

e) Static work load.

f) Degree of stress involved in the job contributed to

by its boring and monotonous nature or lack of

opportunity for initiative, responsibility or individ-

uality.

g) Sudden changes in work rate or fast pace of work.

h) Individual monitoring of work, leading to stress

and work pressure.

i) Vibration, temperature, lighting and glare.

The risk assessment will involve union and management

assessors and reports by competent persons, who should

also assist in implementing the preventive programme.

The employees concerned will be involved in the risk

assessment and be provided with a copy of it.

16.3 Information, education and training

The employer will consult with the union regarding an

education programme for employees, which will

include:

a) Ergonomic principles associated with work equip-

ment, workstations, work patterns, etc.

b) Ways of making necessary adjustments to furni-

ture, equipment, lighting, etc.

c) Regular monitoring of the workplace to ensure it

remains ergonomically sound

d) Exercises for eyes, shoulders, hands, arms, etc., to

prevent excessive strain on the muscles

e) Information on potential hazards associated with

methods of work and the importance of safe work

rates and adequate rest breaks

f) Information on management’s health and safety

policy

g) Information on health and safety reporting and

monitoring systems as well as the signs, symptoms

and management of WRULDs

h) Training of managers and supervisors in the sym-

pathetic handling of known or potential cases

16.4 Work routine

Management and the union agree that a reasonable

work rate varies with the capabilities of individual

employees, the demands of the task and environmen-

tal factors. The availability of rest breaks and pause

exercises (e.g. quick stretching exercises done at the

workstation for 60 seconds every 30 minutes) in work

involving WRULDs risk factors is necessary to avoid

the accumulation of fatigue and strain which con-

tribute to WRULDs. Breaks in work involving WRULDs

risk factors will therefore be provided on the basis of

an assessment of the overall situation and adjusted

accordingly. These breaks and pause exercises should

be in addition to personal health and meal breaks.

16.5 Notification

A notification system will be set up as follows:

a) Employees will be encouraged to report signs and

symptoms of WRULDs.

b) Incidences of such signs and symptoms will be

logged in the accident book.

c) Line managers will have responsibility for monitor-

ing the incidence of signs and symptoms and pro-

posing remedial action, including reviewing the

risk assessment, for employees for whom they are

responsible.

d) Safety representatives will be informed periodical-

ly of the incidence of signs and symptoms in their

area of responsibility and whenever the incidence

rises appreciably.

e) Annual statistics will be supplied to the health and

safety committee.

16.6 Responding to diagnosed conditions

When a case of WRULDs is medically diagnosed, man-

agement will assess necessary action on the basis of

medical advice, including:

a) The extent and nature of the condition

b) The possible causes of the condition

c) The course of treatment recommended

d) The length of time needed for rehabilitation, and

e) The limitations placed on employment in terms of

both tasks and recommended duration of work


The following steps will be taken:

a) A review of the risk assessment of the job involved

by a competent person to be agreed on by both

management and union.

b) Provision of the assessment and reports to the

employee concerned.

c) Implementation, as appropriate, of changes, train-

ing and treatment necessary to enable the employ-

ee to return to his/her position, or of suitable

retraining and redeployment.

d) The granting of access to the workplace to health

professionals who are treating the employee.

e) Training of the employee in the application of

ergonomic and preventive principles.

f) The employer will report a case of WRULD 14 days

after the definitive diagnosis by a doctor to the

Compensation Commissioner and the Dept of

Labour / Minerals and Energy Affairs, as is

required by the COID Act..

g) The employer will submit the subsequently

required reports to the Dept of Labour / Minerals

and Energy Affairs, 3 and 6 months respectively,

after the date the definitive diagnosis was made.

16.7 Redeployment

Where the employee is redeployed, the following will

apply:

a) Job security will be a primary objective and

employees who have to take sick leave will

receive time off with pay until the

Compensation Commissioner reimburses the

company for the temporary total disablement.

(The COID Act determines that an employer will

pay 75% of the employee’s salary for three

months)

b) There will be full consultation with the employee

on career options and procedures prior to any deci-

sions being taken

c) Detailed job descriptions of prospective positions

will be provided to the employee, their treating

medical practitioner and their union

d) Modifications to prospective positions to make

them suitable in the light of the nature of the

condition and treatment will be undertaken where

necessary

e) A gradual return to work will be allowed with no

pressure to return to work until fully ‘fit’

16.8 Monitoring and review

Regular monitoring and annual review of this

policy will be carried out by the health and safety

committee and any difficulties reported to the

person responsible for the implementation of the

policy.


SECTION FADMINISTRATION &

RESOURCES

17Circular Instruction 180 regarding the Compensation

of Work-related Upper Limb Disorders (WRULDs),


Act, 1993 (Act no 130 of 1993), as amended.

Published in the Government Gazette (23 April 2004)

No. 26270; General notices: Notice 498 of 2004

Circular Instruction 180


CIRCULAR INSTRUCTION NO. 180

Circular Instruction 180 regarding the compensationof work-related upper limb disorders (WRULDs)Compensation for Occupational Injuries and Diseases Act, 1993

(Act no 130 of 1993), as amended

The following circular instruction is issued to clarify the compensation of claims for work-related upper limb

disorders (WRULDs) and supersedes all previous instructions in this regard. The Compensation Commissioner‘s

“Guidelines for medical practitioners and employers on how to manage Work-Related Upper Limb Disorders

(WRULDs)” can also be used for further reference. These guidelines are available on the Department of Labour web-

site – www.labour.gov.za – through the CC web page under Occupational Diseases.

1. Definition

WRULDs is a collective term for a group of occupational diseases that consist of musculo-skeletal disorders caused

by exposure in the workplace affecting the muscles, tendons, nerves, blood vessels, joints and bursae of the hand,

wrist, arm and shoulder. These are syndromes associated with characteristic symptoms and physical signs (e.g. rota-

tor cuff syndrome, epicondylitis at the elbow, tenosynovitis and nerve entrapments such as carpal tunnel syndrome).

Previously other terms had been used, such as repetitive strain injury (RSI), cumulative trauma disorder (CTD),

occupational overuse syndrome (OOS), occupational cervico-brachial disorder (OCD), etc. For the purpose of this

instruction the umbrella term, work-related upper limb disorders (WRULDs), will be used.

WRULDs are caused, aggravated or precipitated by one or more of the following risk factors, singly or in combination:

Highly repetitive movements




Awkward sustained postures

Contact stress (e.g. uncomfortable gripping and twisting, sharp edges to hand tools, desk edges, etc.)

Vibration

In terms of this instruction, upper limb musculo-skeletal disorders will be presumed to be work-related if the nature

of the work performed includes exposure to the relevant risk factors.

2. Diagnosis

The following criteria should be used to confirm the diagnosis:

A diagnosis of WRULD by the medical practitioner.

Medical history and clinical signs indicating - site and distribution, quality (type, character), severity (intensi-

ty, frequency, duration) and progression of the symptoms according to the type of disorder

Functional ability report by an occupational therapist and / or physiotherapist, where necessary

Occupational exposure to known risk factors and a chronological relationship between the WRULD and the work

environment.

The confirmatory tests/investigations (e.g. x-rays, strength testing, range of motion testing, nerve conduction

tests), where appropriate.

The medical officers in the Compensation Office will determine whether the diagnosis of WRULD was made accord-

ing to acceptable medical standards.


3. Impairment

Impairment will be determined, in accordance with the internal instructions 157 for residual impairment of the

function of the muscles, tendons, joints or nerves involved, after maximum medical improvement has been reached.

4. Benefits

Benefits will be payable according to the Compensation for Occupational Injuries and Diseases Act, 1993 (Act

number 130 of 1993), as amended.

• Temporary total disablement

Payment for reasonable temporary total or partial disablement will be made on the basis of medical reports for

as long as such disablement continues, for a period not exceeding 24 months.

• Permanent disablement

Permanent disablement will be assessed when a Final Medical Report is received, after a reasonable recovery

period not exceeding 24 months, and failure to perform work effectively after the appropriate course of

treatment and rehabilitation.

• Medical aid

Medical expenses shall be provided for a period of not more than 24 months from the date of the diagnosis. This

period may be extended if, in the opinion of the Director General, further medical aid will reduce the extent of

the disablement. The medical aid covers the costs of diagnosing a WRULD and any necessary treatment

provided by any healthcare provider. The Compensation Commissioner will decide on the need for, the nature

and the sufficiency of the medical aid supplied.

5. Reporting

The following documentation should be submitted to the Compensation Commissioner, or the employer individual-

ly liable, or the mutual association concerned:

W.Cl.1 Employer’s Report of an Occupational Disease

W.Cl.14 Notice of an Occupational Disease and Claim for Compensation

W.Cl.301 First Medical Report in respect of a Work-Related Upper Limb Disorder (WRULD)

All other reports that may be relevant to the diagnosis and treatment of the condition (e.g. an ergonomic

assessment supported by photographs, video clips, etc.)

W.Cl.302 Progress / Final Medical Report in respect of a Work-Related Upper Limb Disorder (WRULD)

Progress medical reports must be submitted monthly to the Compensation Commissioner.

W.Cl. 110 Exposure History or an appropriate employment history

W.Cl.6 Resumption Report (monthly as long as the case is open, even if the employee is at work)

6. Claim Processing

The Office of the Compensation Commissioner will consider and adjudicate upon the liability of all claims. The

medical officers in the Compensation Commissioner’s office are responsible for the medical assessment of a claim

and for the confirmation of the acceptance or rejection of a claim.

DIRECTOR GENERAL: LABOUR

Date: 9 March 2004

Published in the Government Gazette (23 April 2004) No. 26270, General notices: Notice 498 of 2004

18First medical report in respect of a work-related upper

limb disorder (WRULD), published in the Government

Gazette (21 May 2004) No. 26384

W.CL 301: First MedicalReport

1. Date symptoms first started: 2. Date of first consultation: 3. Date of specific diagnosis:

4. Specific diagnosis of this upper limb disorder:

5. The symptoms the employee experiences (tick the appropriate box/es):

Burning sensation Fatiguability Loss of grip strength

Loss of normal sensation Muscle weakness Pain

Paraesthesia (tingling) Sensation of cold Swelling

Stiffness and cramps

Describe:

6. The clinical signs found on examination (tick the appropriate box/es):

Crepitus (crackling sound in subcutaneous tissue) Muscle spasm

Muscle weakness Reduction of range movement

Swelling Tender trigger points in muscles

Tenderness

Describe:

7. Is the employee left or right handed?* Sex:* Age:

8. Height of employee: Weight of employee: Body mass index:

9. Which special medical investigation/s and/or job analysis / ergonomic assessments were done to prove the diagnosis and/or what other poten-tial causes of the above-mentioned upper limb disorder have been investigated / eliminated? (Where applicable, please attach these reports.

10. Does the employee suffer from any other diseases? (If so, please specify)

11. Describe the nature of any previous injuries sustained and/or abnormalities to the employee’s upper limb/s?

Employee: Surname: Identity number:

First names:

Address: Code:

Employer:

Address: Code:

FIRST MEDICAL REPORT IN RESPECT OF A WORK-RELATED UPPER LIMB DISORDER (WRULD)

Compensation for Occupational Injuries and Diseases Act, 1993 (Act number 130 of 1993)[Section 6A(b) – Commissioner’s rules, forms and particulars – Annexure 25]

This form must be completed by a medical practitioner and sent to the Compensation Commissioner, PO Box 955, Pretoria, 0001

Right Left Male Female years

cm kg

Claim number:

W.CI. 301

Please turn over and complete reverse side.*Encircle correct answer

I certify that I have by examination of the employee, satisfied myself of the above-mentioned facts.

Signature Registered address with HPCSA:

(Medical Practitioner):

Name (printed):

Qualifications: Code:

Practice number: Date (Important):

12. Appraise the job or summarise the job analysis / ergonomic assessment of the job which has allegedly caused the disorder, in terms ofthese risk factors (Where applicable, attach photos, diagrams and/or job analysis / ergonomic assessment):

13. How long has the employee been doing this job? years months

14. Explain how this alleged occupational disease progressed over a period of time in terms of function (i.e. signs and symptoms with relationto job tasks) [E.g. wrist pain started after 8 hours of sewing 6 months ago (no clinical signs). Currently increased pain after 30 minutes of sewing with pain keeping her out of

sleep. Positive Phalen and Tinel tests and reduction in grip strength.]

15. Have any of the employee’s colleagues, performing a similar job, complained of similar symptoms? If yes, explain.

16. Explain how this condition was managed before this specific diagnosis was made in terms of:

a) The Person Medically (e.g. medication, surgery, etc.):

Functionally (e.g. rehabilitation, etc.):

b) The Job Task adaptation (e.g. job rotation, shorter hours, etc.):

Equipment adaptation (e.g. extended handle on tool used, etc.):

17. Is the employee currently fit to work?* If yes, is he/she performing his/her* or ?

If the employee is performing alternate/adapted work, is this position* or ?

Yes No

Yes No Alternate/Adapted workUsual work

Temporary Permanent

Risk factor Percentage of Briefly describe the job task where this risk factor occurs and quantify in terms of repetitions / working day duration / strength required / range of movement, etc.

Repetitive movements





Contact stress

Vibration

Low temperatures

IMPORTANT: • All questions must be answered in full (use extra paper if necessary).

• Full motivation of diagnosis will prevent unnecessary correspondence and delays in adjudication of claim.

• The form must be forwarded to the employer within 14 days after the specific diagnosis was made. The employer must forward this report to the Compensation Commissioner.

• Please submit medical accounts separately. Attach a copy of this report to your account.

• It is advisable to consult the Compensation Commissioner’s “Guidelines for Managing Work-Related Upper Limb Disorders” before reporting this condition.

• The employer must submit a copy of this report to the Provincial Executive Manager of the Department of Labour (Occupational Health and Safety Act) or the Regional Principal Inspector of Mines (Mine Health and Safety Act)

• The employer must submit a Progress Medical Report (W.Cl. 302) and a Resumption Report (W.Cl. 6) on a monthly basis to the Compensation Commissioner or Mutual Association or employer individually liable, as the case may be, until the employee’s condition has become stabilised, when a Final Medical Report (W.Cl. 302) should be submitted.

*Encircle correct answer

W.CI. 301

19Progress/Final medical report in respect of a work-

related upper limb disorder (WRULD), published in

the Government Gazette (21 May 2004) No. 26384

W.CL 302: Progress/Final medical report

B. COMPLETE THE FOLLOWING SECTION ONLY IF THE EMPLOYEE IS CURRENTLY NOT WORKING DUE TO THIS CONDITION

3. Is the employee still in the employment of the above-mentioned employee? If yes, answer the following questions:

a. Since when is the employee not working because of this occupational disease? (Date)

b. When do you expect the employee to return to work? (Date)

c. Will the employee be returning to his/her usual job?**

i. If yes, are there any task adaptations?* If yes, please explain (e.g. job rotation, shorter hours)

ii. If yes, are there any equipment adaptations? ** If yes, please explain (e.g. extended handle on tool used)

d. Is the employee returning to an alternate position?** If yes, is this position or ?**

e. What arrangements have been made with the employer regarding the employee’s re-introduction to work (e.g. work hardening, shorter hours, etc.)?

Employee: Surname: Identity number:

First names:

Address:

Employer:

Address:

Specific diagnosis: Date of specific diagnosis:

Code:

Code:

A. CURRENT CLINICAL CONDITION OF EMPLOYEE (Complete this section)

1. Since the previous Medical Report, is there an improvement in the severity of the symptoms the employee is experiencing and clinical signs found on examination?** Explain.

2. Describe how the employee’s condition has been managed since the previous report (mention dates of procedures, tests, etc.) in terms ofthe following:

a. Medically (e.g. medication, surgery, etc.)

b. Functionally (e.g. rehabilitation, etc.)

PROGRESS / FINAL* MEDICAL REPORT IN RESPECT OF A WORK-RELATED UPPER LIMB DISORDER (WRULD)

Compensation for Occupational Injuries and Diseases Act, 1993 (Act number 130 of 1993)[Section 6A(b) – Commissioner’s rules, forms and particulars – Annexure 26]

This form must be completed by a medical practitioner and sent to the Compensation Commissioner, PO Box 955, Pretoria, 0001

YES NO

YES NO

YES NO

Claim number:

YES NO

YES NO

YES NO

TEMPORARY PERMANENT

*Delete which is not applicable **Encircle the correct answerW.CI. 302 Please turn over and complete reverse side.

I certify that I have by examination of the employee satisfied myself of the above-mentioned facts.

Signature Registered address with HPCSA:

(Medical Practitioner):

Name (printed):

Qualifications: Code:

Practice number: Date (Important):

D. PROGNOSIS (Complete this section)

11. Has the employee’s condition been optimally managed since the previous Medical Report in terms of medical treatment and actions taken in response to the functional capacity and job analysis / ergonomics assessments? If no, please explain.

12. a. Has the employee’s condition become stabilised (i.e. reasonable medical intervention will not improve the employee’s condition)?

b. If yes, has there been any permanent anatomical defect and/or impairment of functions as a result of this occupational disease? If yes, describe this in detail and substantiate by special reports where necessary.

7. Did the employee receive a planned re-introduction when returning to work?**

8. Are you aware of any adaptation to the workplace that are planned / implemented by the employer to prevent other employees from developing WRULDs?**

9. Are you aware of an occupational health programme that is in place to assess the health risks causing WRULDs and to do adequate medical surveillance and health education?**

10. Are you aware of a company policy to address WRULDs?**

C. COMPLETE THE FOLLOWING SECTION ONLY IF THE EMPLOYEE IS CURRENTLY AT WORK:

4. Was the employee off work for more than 2 days due to this condition?**

If yes, the period the employee was not at work, was from (inclusive) to (Dates)

5. Has the employee returned to his/her usual job?**

a. If yes, are there any task adaptations?* If yes, please explain (e.g. job rotation, shorter hours)

b. If yes, are there any equipment adaptations? ** If yes, please explain (e.g. extended handle on tool used)

6. Has the employee returned to an alternate position?** If yes, is this position** or ?

If yes, then analyse the job that the employee has returned to in terms of the risk factors below:

Risk factor Percentage of Briefly describe the job task where this risk factor occurs and quantify in terms of working day repetitions / duration / strength required / range of movement, etc.

Repetitive movements





Contact stress

Vibration

Low temperatures

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

TEMPORARY PERMANENT

YES NO

YES NO

YES NO

IMPORTANT: • All questions must be answered in full (use extra paper if necessary).

• The form must be forwarded to the employer who will send it to the Compensation Commissioner.

• Please submit medical accounts separately. Attach a copy of this report to your account.

• It is advisable to consult the Compensation Commissioner’s “Guidelines for Managing Work-Related Upper Limb Disorders” before completing this report.

• The employer must submit a copy of this report to the Provincial Executive Manager of the Department of Labour (Occupational Health and Safety Act) or the Regional Principal Inspector of Mines (Mine Health and Safety Act).

• A Progress Medical Report (W.Cl. 302) and a Resumption Report (W.Cl. 6) must be submitted by the employer on a monthly basis to the Compensation Commissioner or Mutual Association or employerindividually liable, as the case may be, until the employee’s condition has become stabilised, when a Final Medical Report (W.Cl. 302) should be submitted.

**Encircle correct answerW.CI. 302

20The contact details of the Compensation

Commissioner and the Provincial Executive Managers

of the Department of Labour

Reporting – the contactdetails


REPORTING – The contact details1

The employer must submit the necessary forms to the Compensation Commissioner.

The employer must also notify the Provincial Executive Manager of the Department of Labour (Occupational

Health and Safety Act) of a case of WRULD.

The employer must submit a Progress Medical Report (W.Cl. 302) and a Resumption Report (W.Cl. 6) on a

monthly basis to the Compensation Commissioner or Mutual Association or employer individually liable, as the

case may be, until the employee’s condition has become stabilised, when a Final Medical Report (W.Cl. 302)

should be submitted.

REGION POSTAL ADDRESS PHONE FAX

E A S T E R N C A P E P R I VAT E B A G X 9 0 0 5 0 4 3 7 0 1 3 1 2 8 0 4 3 7 2 2 1 0 1 2E A S T L O N D O N5 2 0 0

F R E E S TAT E P. O . B O X 5 2 2 0 5 1 5 0 5 6 2 0 3 0 5 1 4 4 8 5 3 2 9B L O E M F O N T E I N9 3 0 0

G A U T E N G N O R T H P R I VAT E B A G 3 9 3 0 1 2 3 0 9 5 0 6 5 0 1 2 3 2 0 2 3 6 7P R E T O R I A0 0 0 1

G A U T E N G S O U T H P O B O X 4 5 6 0 0 1 1 4 9 7 3 0 4 7 0 1 1 4 9 7 3 2 2 5J O H A N N E S B U R G2 0 0 0

K W A Z U L U - N ATA L P O B O X 9 4 0 0 3 1 3 6 6 2 0 2 2 0 3 1 3 0 5 9 5 4 0D U R B A N4 0 0 0

L I M P O P O P R I VAT E B A G X 9 3 6 8 0 1 5 2 9 0 1 6 0 7 0 1 5 2 9 0 1 6 0 8P O L O K WA N E0 7 0 0

M P U M A L A N G A P R I VAT E B A G X 7 2 6 3 0 1 3 6 5 5 8 7 0 1 0 1 3 6 5 5 8 8 3 8W I T B A N K1 0 3 5

N O R T H E R N C A P E P R I VAT E B A G X 5 0 1 2 0 5 3 8 3 8 1 5 0 2 0 5 3 8 3 2 9 3 8 6K I M B E R L E Y8 3 0 1

N O R T H W E S T P R I VAT E B A G X 2 0 4 0 0 1 8 3 8 7 8 1 0 0 0 1 8 3 8 4 2 5 9 7M M A B AT H O ( E X T. 1 0 1 )2 7 4 5

W E S T E R N C A P E P R I VAT E B A G X 8 7 2 0 2 1 4 2 1 0 8 0 2 0 2 1 4 2 5 2 3 9 2C A P E T O W N8 0 0 0

COMPENSATION COMMISSIONER

P O B O X 9 5 5 T E L : 0 1 2 3 2 1 0 2 4 5

P R E T O R I A FA X : 0 1 2 3 2 4 4 4 5 1

0 0 0 1 E - M A I L : I N F O @ W C O M P. G O V. Z A

W E B : W W W. L A B O U R . G O V. Z A

DEPARTMENT OF LABOUR: CHIEF INSPECTOR

OCCUPATIONAL HEALTH AND SAFETY

PROVINCIAL EXECUTIVE MANAGERS OF THE DEPARTMENT OF LABOUR

P R I VAT E B A G X 1 1 7 T E L : 0 1 2 3 0 9 4 3 7 7

P R E T O R I A FA X : 0 1 2 3 2 0 0 9 2 3

0 0 0 1 W E B : W W W. L A B O U R . G O V. Z A

1 As on 1 April 2004

21In many cases employer, line managers or supervisors

will be quite capable of assessing WRULD risks and

taking appropriate action. However, an employer

should get further advice if:

There is uncertainty whether a significant risk exists;

Simple and cheap corrective measures are not

available;

The right action to handle a risk is not obvious; or

If numerous employees are developing WRULDs.

Where help is needed, and no one else in the organi-

sation has the answer, an employer should seek expert

advice. The following organisations (in alphabetical

order) may be able to point an employer in the right

direction:

Getting further advice


Getting futher adviceIn many cases employers, line managers or supervisors will be quite capable of assessing WRULD risks and taking

appropriate action. However, an employer should get further advice if:

There is uncertainty whether a significant risk exists

Simple and cheap corrective measures are not available

The right action to handle a risk is not obvious or

If numerous employees are developing WRULDs.

Where help is needed, and no one else in the organisation has the answer, an employer should seek expert advice.

The following organisations (in alphabetical order) may be able to point an employer in the right direction:

AFROX OCCUPATIONAL HEALTHCARE

At ten t ion : Dr S te fanus Snyman

PO BOX 474 TEL: 082 557 1056

GOODWOOD FAX: 086 670 1842

CAPE TOWN E-MAIL: [email protected]

7459 WEB: WWW.OCCHEALTH.GIVENGAIN.NET

CSIR MINING TECHNOLOGYAt ten t ion : Mr Schu Schut te

Dr Bel inda Dias

P O BOX 91230 TEL: 011 358 0202 / 011 358 0291

AUCKLAND PARK FAX: 011 482 3267

2006 E-MAIL: [email protected]

WEB: WWW.CSIR.CO.ZA/MININGTEK

ERGOMAX (PTY) LTD(ERGONOMIC CONSULTANTS)

At ten t ion : Dale Kennedy

UNIT B6 TEL: 021 702 2001 OR 011 791 1616

WESTLAKE SQUARE FAX: 021 701 1117

WESTLAKE MOBILE: 082 462 54 86 OR 072 321 9227

7945 E-MAIL: [email protected] OR

[email protected]

WEB: WWW.ERGOMAX.CO.ZA

ERGONOMIC SOCIETY OF SOUTH AFRICA (ESSA)

can advise on f inding a consultant ergonomist (a special ist in ensuring a good ‘ f i t ’ between

employees and their ‘ job’ requirements) .

At ten t ion : Jon James

C/O DEPARTMENT OF HUMAN KINETICS AND ERGONOMICS

RHODES UNIVERSITY TEL: 046 6038468

GRAHAMSTOWN E-MAIL: J . [email protected]

6140 WEB: WWW.ERGONOMICS-SA.ORG.ZA

OCCUPATIONAL THERAPYASSOCIATION OF

SOUTH AFRICA (OTASA)At ten t ion : Mrs B . Badenhors t

PO BOX 11695 TEL: 012 342 6731

HATFIELD FAX: 012 342 5400


WEB: WWW.OTASA.ORG.ZA

SOUTH AFRICAN SOCIETY OFOCCUPATIONAL HEALTH

NURSES (SASOHN)At ten t ion : L inda Stokes

P.O.BOX 18793 TEL: 011-8923174

SUNWARD PARK E-MAIL: : [email protected]

1470 WEB: WWW.SASOHN.ORG.ZA


SOUTH AFRICAN SOCIETY OFOCCUPATIONAL MEDICINE

(SASOM)At ten t ion : Dr F iona Robinson

(Tel : 011 315 1926)Pro f Mary Ross

(Tel : 011 358 9183)

PO BOX 16179 TEL: 012 667 5160/1

LYTTLETON FAX: 012 667 5160


WEB: WWW.SASOM.ORG.ZA

SOUTH AFRICAN SOCIETY OFPHYSIOTHERAPY

At ten t ion : Sai ra Khan

P O BOX 92125 TEL: 011 4851467

NORWOOD FAX: : 011 4851613


WEB: WWW.PHYSIOSA.ORG.ZA

WORKABIL ITY – PREVENTION,ASSESSMENT & WORK

REHABIL ITATION SERVICESAt ten t ion : L indsay Scot t

L ize S labber t

PO BOX 51784 TEL 021 551 9108

WEST BEACH FAX: 021 5519108


22This checklist is reproduced with the permission of

the Health & Safety Executive. HSE (1998)

Checklist: WRULDs inthe workplace

Page | 1 | of Checklist© 2004 | Compensation Commissioner’s Guidelines for Health Practitioners and Employers to manage WRULDs | Version 1.0

INITIAL ASSESSMENT YES NO

CHECKLIST: WRULDs IN THE WORKPLACE1

Company / Department:

Workstation: Completed by:

Task:

Worker: Date:

RISK FACTOR TICK YOURANSWER ACTION REQUIRED

If you have no ticks in the “YES” column onthis page, you are unlikely to have anyWRULDs. You need not go on to the followingpages.

However, if you have any ticks in the “YES”column on this page, there may be a risk ofWRULDs in your workplace. You should go onand complete the full risk assessment on thefollowing pages.

** ‘Awkward’ includes ‘staying in one position for a long

time’ and ‘holding things for a long time’

ARE THERE ANY WARNING SIGNS OF UPPER LIMB DISORDERS? For example:

Gripping (a tool or work piece)?

Squeezing (e.g. tool handles)?

Twisting?

Reaching?

Moving things (pushing, pulling, lifting)?

Finger/hand movements (e.g. keyboard work)?

Actual cases of possible WRULDs in this or similar work?

Complaints by employees, e.g. aches and pains in hands, wrists, arms, shoulder, etc.? Ask youremployees if they have any of these symptoms.

Home-made, improvised changes to workstations or tools? (e.g. handles cushioned or madelonger)

DOES THE JOB INVOLVE MUCH

FREQUENTorFORCEFULorAWKWARD**

1 This checklist is reproduced with the permission of the Health & Safety Executive. HSE (1998)


FULL RISK ASSESSMENT

RISK FACTOR YES NO POSSIBLE SOLUTIONS

Are there any factors in the job that make WRULDs likely, such as NEED FOR MUCH FORCE?

Does the job involve: RECOMMENDATIONS FOR ACTION

1. Strong force at the same time as Redesign workstation or tool, e.g. awkward movements or posture • Reposition supply of components to reduce (e.g. static loading, bent wrists, reaching requiredwork with arms raised or fully • Move controls to more convenient positionextended)?

2. Forceful use of hand/forearm • Redesign job, workstation, and/or tools to avoid muscles? over-use of the hand or forearm

• Maintain tools for ease of use.(e.g. keep them sharp and lubricated

• Assess improved job rotation / sharing

3. Trying to make do with ill-fitting • Improve quality of components, or provide suitablecomponents by forcing them into tools for fitting themplace?

4. Tools not ideal for repetitive or • Replace domestic or DIY hand tools with tools designed frequent use – particularly if for repetitive industrial use squeezing, twisting or hammering • Redesign tool handles to achieve even distribution of actions are required? force across the hand (adequate size of the handle and

power grip preferable to pinch grip) and straight rather than bent wrists. Consider replacing hand tools with power tools. Reduce squeezing forces by using weaker springs in triggers, etc.

5. Using equipment designed for a • Redesign equipment or tool (e.g. counter-balancing to larger or stronger person (e.g. reduce force required)women using tools designed • Provide powered version for men)?



Are there any factors in the job that make WRULDs likely, such as RAPID, AWKWARD OR FREQUENT MOVEMENTS?


1. Machine pacing • Self-pacing is preferable(e.g. to keep up with conveyor)?

2. Frequent repetitions of the • Re-plan work, e.g. break up pause/repetition cyclessame small number of or spread movement across both hands. Consider movements? adding extra activities to job, to give variety. Consider

scope for automation or use of power tools.

3. Awkward movements such as • Redesign workstation, controls or shape of tool handlestwisting or rotation of wrist, movements of wrist from side to side,very bent fingers and wrist, or hand or arm movements beyond a comfortable range?

4. Pressure on employees to work • Consider need for such systems (but employees mayfast, e.g. perform piecework or resist change). Better training in WRULD risks may bonus system? help.



Are there any factors in the job that make WRULDs likely, such as AWKWARD OR STATIC POSTURE?


1. Cramped body position, and/or • Improve space available to worker. Provide adjustablenot enough space to change workstation (especially chair) for employees who are posture? above or below average height or shape.

2. Arms stretching out or at shoulder • Move materials or controls to more convenient position.height or above for long periods?

3. Work at awkwardly high or low • Move materials or controls to more convenient position.height (crouching, stooping, or reaching up)?

4. Poor posture for any other reason? • Has worker been trained in good working techniques and posture?

• Is there a need for better seating (adjustable to correctheight for individual) footrests, etc.?

• Sitting versus standing position?



Are there any factors in the job that make WRULDs likely, such as AWKWARD OR STATIC POSTURE?


1. No changes to work routine or • If possible, vary tasks to provide changes in activity.variation of tasks? If not, check that there is adequate rest breaks

2. No breaks or infrequent breaks? • Check that breaks are taken, especially if work involvescontinuous effort such as holding tools, or rapidlyrepeated movements (e.g. typing)

• Pause exercises, e.g. quick stretches / movements atworkstation for 60 seconds every 30 minutes

3. Worker not able to have short • Redesign work to make short breaks possiblepauses when desired?

Are there any factors in the job that make WRULDs likely, such as NO SPECIAL ARRANGEMENT FOR NEW EMPLOYEES?

1. People having to work at full pace • Allow recruits to build up their work rate sensibly as immediately on starting (or they gain experienceresuming) the job?

2. No training in risks of WRULDs • Provide training in skills, posture and warningand ways employees can reduce symptoms for all those at riskrisks?




Are there any factors in the job that make WRULDs likely, such as POOR ENVIRONMENTAL CONDITIONS

1. In dim light, shadow or flickering • Provide better lighting so that employees do not havelight? to adopt awkward postures to see properly

2. In cold or otherwise adverse • Cold (e.g. handling frozen foods) may increase the riskconditions? of WRULDs. If it is not possible to warm the working

environment, check that protective clothing is welldesigned and does not affect posture or grip

3. With tools that vibrate? • Consider whether job can be done another way to avoidneed for high-vibration tools. Or provide vibration-absorbing grip and minimise vibration by proper maintenance.

Is the job performed: RECOMMENDATIONS FOR ACTION

23This bibliography contains more references than

referred to in the text. Various individuals and profes-

sional interest groups commented on the draft docu-

ments in developing these guidelines and most of

them mentioned additional sources and references.

We considered it valuable to include everything in this

bibliography.

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